- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $2,398.83 / $5,754.40
| Facility | | $707.95 | $2,398.83 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $446.68 / $1,202.26
| Professional | | $97.72 | $446.68 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $707.95 / $707.95
| Professional | | $707.95 | $707.95 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $1,479.11 / $3,235.94
| Facility | | $758.58 | $1,479.11 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $213.80 / $933.25
| Professional | | $114.82 | $213.80 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $676.08 / $1,023.29
| Professional | | $97.72 | $676.08 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $2,630.27 / $4,677.35
| Facility | | $1,698.24 | $2,630.27 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $323.59 / $1,096.48
| Professional | | $104.71 | $323.59 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $588.84 / $1,513.56
| Facility | | $93.33 | $588.84 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $891.25 / $4,897.79
| Professional | | $588.84 | $891.25 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,148.15 / $2,884.03
| Facility | | $954.99 | $1,148.15 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $467.74 / $1,023.29
| Professional | | $100.00 | $467.74 | $1,023.29 |