- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $1,202.26 / $1,778.28
| Professional | | $537.03 | $1,202.26 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $144.54
| Professional | | $144.54 | $144.54 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $758.58 / $1,445.44
| Facility | | $295.12 | $758.58 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $380.19 / $676.08
| Professional | | $229.09 | $380.19 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $426.58 / $426.58
| Professional | | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $1,000.00 / $1,995.26
| Facility | | $234.42 | $1,000.00 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $331.13 / $489.78
| Professional | | $79.43 | $331.13 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $489.78 / $1,230.27
| Facility | | $79.43 | $489.78 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $1,380.38 / $3,019.95
| Professional | | $269.15 | $1,380.38 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,454.71 / $2,454.71 / $2,454.71
| Professional | | $2,454.71 | $2,454.71 | $2,454.71 |