- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $204.17 / $2,137.96
| Facility | | $102.33 | $204.17 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $91.20 / $239.88
| Professional | | $85.11 | $91.20 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $162.18 / $177.83
| Facility | | $91.20 | $162.18 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $1,174.90
| Professional | | $91.20 | $91.20 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $208.93 / $281.84
| Facility | | $141.25 | $208.93 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $239.88
| Professional | | $120.23 | $120.23 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,548.82 / $1,548.82
| Professional | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $223.87 / $1,737.80
| Facility | | $87.10 | $223.87 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $295.12
| Professional | | $123.03 | $123.03 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $0.60 / $154.88
| Professional | | $0.60 | $0.60 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $257.04 / $288.40
| Facility | | $120.23 | $257.04 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $97.72 / $169.82
| Professional | | $87.10 | $97.72 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,995.26 / $1,995.26 / $2,238.72
| Facility | | $1,995.26 | $1,995.26 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $6,165.95 / $6,165.95 / $6,165.95
| Professional | | $6,165.95 | $6,165.95 | $6,165.95 |