- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $1,071.52 / $1,230.27
| Facility | | $616.60 | $1,071.52 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $549.54 / $954.99
| Professional | | $288.40 | $549.54 | $954.99 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $2,238.72
| Facility | | $645.65 | $645.65 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $363.08 / $1,148.15
| Professional | | $208.93 | $363.08 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $416.87 / $741.31
| Facility | | $398.11 | $416.87 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $446.68 / $645.65
| Professional | | $288.40 | $446.68 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $1,202.26 / $1,548.82
| Facility | | $199.53 | $1,202.26 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $501.19 / $831.76
| Professional | | $288.40 | $501.19 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $776.25 / $3,019.95
| Facility | | $549.54 | $776.25 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $389.05 / $3,235.94
| Professional | | $173.78 | $389.05 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $645.65 / $776.25
| Facility | | $229.09 | $645.65 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $323.59 / $776.25
| Professional | | $173.78 | $323.59 | $776.25 |