- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $1,698.24 / $5,623.41
| Facility | | $177.83 | $1,698.24 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $229.09 / $467.74
| Professional | | $109.65 | $229.09 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $1,778.28 / $3,981.07
| Facility | | $676.08 | $1,778.28 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $141.25 / $245.47
| Professional | | $114.82 | $141.25 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $239.88 / $338.84
| Professional | | $109.65 | $239.88 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Facility | | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $257.04 / $489.78
| Professional | | $138.04 | $257.04 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $257.04 / $1,380.38
| Facility | | $104.71 | $257.04 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $407.38 / $2,630.27
| Professional | | $257.04 | $407.38 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $1,047.13 / $2,089.30
| Facility | | $630.96 | $1,047.13 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $263.03 / $489.78
| Professional | | $125.89 | $263.03 | $489.78 |