- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $3,801.89 / $12,589.25
| Facility | | $263.03 | $3,801.89 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $239.88 / $575.44
| Professional | | $93.33 | $239.88 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $194.98 / $302.00
| Professional | | $112.20 | $194.98 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,621.81 / $3,162.28
| Facility | | $1,258.93 | $1,621.81 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $154.88 / $251.19
| Professional | | $95.50 | $154.88 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $251.19 / $371.54
| Professional | | $162.18 | $251.19 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $186.21 / $1,230.27
| Facility | | $102.33 | $186.21 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $275.42 / $1,000.00
| Professional | | $154.88 | $275.42 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $251.19 / $371.54
| Professional | | $186.21 | $251.19 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $251.19 / $295.12
| Professional | | $190.55 | $251.19 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $1,047.13 / $3,801.89
| Facility | | $251.19 | $1,047.13 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $186.21 / $316.23
| Professional | | $102.33 | $186.21 | $316.23 |