- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $416.87 / $776.25
| Professional | | $323.59 | $416.87 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $588.84 / $1,380.38
| Professional | | $363.08 | $588.84 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,096.48 / $1,737.80
| Facility | | $933.25 | $1,096.48 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $891.25 / $1,122.02
| Professional | | $407.38 | $891.25 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $446.68 / $691.83
| Facility | | $371.54 | $446.68 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $776.25 / $1,000.00
| Professional | | $676.08 | $776.25 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $467.74 / $870.96
| Facility | | $363.08 | $467.74 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $707.95 / $2,691.53
| Professional | | $380.19 | $707.95 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $58.88 / $407.38
| Professional | | $32.36 | $58.88 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $870.96 / $1,071.52
| Professional | | $870.96 | $870.96 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $1,000.00 / $1,445.44
| Professional | | $575.44 | $1,000.00 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $954.99 / $2,691.53
| Facility | | $660.69 | $954.99 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $1,778.28 / $2,691.53
| Professional | | $407.38 | $1,778.28 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $524.81 / $1,071.52
| Professional | | $489.78 | $524.81 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $616.60 / $1,737.80
| Professional | | $100.00 | $616.60 | $1,737.80 |