- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $3,801.89 / $12,589.25
| Facility | | $691.83 | $3,801.89 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $295.12 / $776.25
| Professional | | $131.83 | $295.12 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $1,949.84 / $3,801.89
| Facility | | $1,513.56 | $1,949.84 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $288.40 / $602.56
| Professional | | $162.18 | $288.40 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $724.44 / $724.44
| Facility | | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $446.68 / $870.96
| Professional | | $288.40 | $446.68 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $363.08 / $1,318.26
| Facility | | $165.96 | $363.08 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $588.84 / $2,290.87
| Professional | | $346.74 | $588.84 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $575.44 / $870.96
| Professional | | $309.03 | $575.44 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $724.44 / $724.44
| Facility | | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $446.68 / $1,000.00
| Professional | | $275.42 | $446.68 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,548.82 / $5,248.07
| Facility | | $1,096.48 | $1,548.82 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $363.08 / $741.31
| Professional | | $177.83 | $363.08 | $741.31 |