- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $2,187.76 / $4,570.88
| Facility | | $467.74 | $2,187.76 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $416.87 / $1,023.29
| Professional | | $194.98 | $416.87 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $162.18 / $223.87 / $977.24
| Professional | 52 | $162.18 | $223.87 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- 53
- Typical Low / Median / Typical High
- $63.10 / $194.98 / $588.84
| Professional | 53 | $63.10 | $194.98 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $190.55 / $416.87
| Professional | | $173.78 | $190.55 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $50.12 / $50.12 / $50.12
| Professional | 52 | $50.12 | $50.12 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- 53
- Typical Low / Median / Typical High
- $190.55 / $190.55 / $190.55
| Professional | 53 | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,801.89 / $4,073.80 / $5,888.44
| Facility | | $3,801.89 | $4,073.80 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $281.84 / $467.74
| Professional | | $194.98 | $281.84 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $575.44 / $575.44
| Facility | | $575.44 | $575.44 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $398.11 / $758.58
| Professional | | $213.80 | $398.11 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4.57 / $309.03 / $724.44
| Professional | | $4.57 | $309.03 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $691.83 / $691.83
| Facility | | $691.83 | $691.83 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.98 / $263.03 / $724.44
| Professional | | $3.98 | $263.03 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $478.63 / $870.96
| Professional | | $173.78 | $478.63 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $1,737.80 / $3,235.94
| Facility | | $588.84 | $1,737.80 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $407.38 / $724.44
| Professional | | $204.17 | $407.38 | $724.44 |