- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $2,344.23 / $5,888.44
| Facility | | $316.23 | $2,344.23 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $302.00 / $2,398.83
| Professional | | $141.25 | $302.00 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $426.58 / $2,454.71
| Professional | | $338.84 | $426.58 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $954.99 / $1,318.26
| Professional | | $151.36 | $954.99 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $2,041.74 / $5,248.07
| Facility | | $371.54 | $2,041.74 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- 53
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $134.90
| Facility | 53 | $134.90 | $134.90 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $1,548.82 / $3,090.30
| Professional | | $398.11 | $1,548.82 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $1,778.28 / $2,398.83
| Professional | | $371.54 | $1,778.28 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $467.74 / $2,511.89
| Professional | | $407.38 | $467.74 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $323.59 / $1,659.59
| Professional | | $141.25 | $323.59 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $4,168.69 / $6,309.57
| Facility | | $2,398.83 | $4,168.69 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $870.96 / $2,630.27
| Professional | | $177.83 | $870.96 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $323.59 / $1,778.28
| Professional | | $275.42 | $323.59 | $1,778.28 |