- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $2,089.30 / $2,089.30
| Facility | | $128.82 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $2,089.30 / $2,398.83
| Professional | | $2,089.30 | $2,089.30 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $2,238.72 / $2,344.23
| Facility | | $1,737.80 | $2,238.72 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $2,238.72 / $2,344.23
| Professional | | $2,187.76 | $2,238.72 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $208.93 / $229.09
| Facility | | $144.54 | $208.93 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $204.17 / $2,691.53
| Professional | | $125.89 | $204.17 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $2,691.53 / $4,365.16
| Facility | | $398.11 | $2,691.53 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,238.72 / $2,238.72 / $3,311.31
| Professional | | $2,238.72 | $2,238.72 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $269.15 / $2,691.53
| Professional | | $204.17 | $269.15 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $208.93 / $309.03
| Facility | | $169.82 | $208.93 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $2,511.89 / $5,495.41
| Professional | | $208.93 | $2,511.89 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $4,168.69 / $9,120.11
| Facility | | $102.33 | $4,168.69 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $141.25 / $2,754.23
| Professional | | $125.89 | $141.25 | $2,754.23 |