- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,174.90
| Facility | | $1,174.90 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,174.90 / $1,621.81
| Professional | | $891.25 | $1,174.90 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,949.84 / $2,691.53
| Professional | | $1,122.02 | $1,949.84 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,412.54 / $2,511.89
| Professional | | $1,000.00 | $1,412.54 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,445.44 / $1,445.44
| Professional | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,288.25 / $1,995.26
| Facility | | $1,000.00 | $1,288.25 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $758.58 / $2,290.87
| Professional | | $758.58 | $758.58 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $1,698.24 / $1,862.09
| Professional | | $741.31 | $1,698.24 | $1,862.09 |
- 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
- $812.83 / $1,071.52 / $1,819.70
| Professional | | $812.83 | $1,071.52 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8,128.31 / $8,128.31 / $9,332.54
| Professional | | $8,128.31 | $8,128.31 | $9,332.54 |