- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $1,174.90 / $1,174.90
| Facility | | $128.82 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,348.96
| Professional | | $1,174.90 | $1,174.90 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,258.93 / $1,318.26
| Facility | | $1,000.00 | $1,258.93 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,258.93 / $1,318.26
| Professional | | $1,258.93 | $1,258.93 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $208.93 / $229.09
| Facility | | $144.54 | $208.93 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $1,047.13 / $1,445.44
| Professional | | $125.89 | $1,047.13 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $1,445.44 / $2,290.87
| Facility | | $218.78 | $1,445.44 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,412.54
| Professional | | $1,174.90 | $1,174.90 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $1,412.54 / $1,445.44
| Professional | | $109.65 | $1,412.54 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $208.93 / $309.03
| Facility | | $169.82 | $208.93 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $1,318.26 / $2,884.03
| Professional | | $114.82 | $1,318.26 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $1,445.44 / $3,162.28
| Facility | | $102.33 | $1,445.44 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $141.25 / $1,202.26
| Professional | | $125.89 | $141.25 | $1,202.26 |