- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $3,162.28 / $7,413.10
| Facility | | $1,348.96 | $3,162.28 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $1,023.29 / $2,187.76
| Professional | | $263.03 | $1,023.29 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $524.81 / $2,754.23
| Professional | | $234.42 | $524.81 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,238.72 / $4,677.35 / $10,000.00
| Facility | | $2,238.72 | $4,677.35 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $1,023.29 / $2,041.74
| Professional | | $263.03 | $1,023.29 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $1,174.90 / $1,778.28
| Professional | | $239.88 | $1,174.90 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $426.58 / $426.58
| Facility | | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $794.33 / $2,511.89
| Professional | | $302.00 | $794.33 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $1,412.54 / $3,715.35
| Facility | | $263.03 | $1,412.54 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $2,398.83 / $9,332.54
| Professional | | $1,445.44 | $2,398.83 | $9,332.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $3,019.95 / $5,128.61
| Facility | | $2,137.96 | $3,019.95 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $1,230.27 / $2,511.89
| Professional | | $269.15 | $1,230.27 | $2,511.89 |