- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $3,801.89 / $12,589.25
| Facility | | $190.55 | $3,801.89 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $104.71 / $489.78
| Professional | | $63.10 | $104.71 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $891.25 / $1,737.80
| Facility | | $691.83 | $891.25 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $109.65 / $162.18
| Professional | | $67.61 | $109.65 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $83.18
| Facility | | $83.18 | $83.18 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $162.18 / $204.17
| Professional | | $89.13 | $162.18 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $114.82 / $371.54
| Facility | | $67.61 | $114.82 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $169.82 / $478.63
| Professional | | $95.50 | $169.82 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $190.55 / $239.88
| Professional | | $141.25 | $190.55 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $83.18
| Facility | | $83.18 | $83.18 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $190.55 / $269.15
| Professional | | $125.89 | $190.55 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $1,047.13 / $3,801.89
| Facility | | $380.19 | $1,047.13 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $128.82 / $204.17
| Professional | | $77.62 | $128.82 | $204.17 |