- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,445.44 / $1,445.44
| Facility | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $1,096.48 / $1,445.44
| Professional | | $87.10 | $1,096.48 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $138.04 / $165.96
| Facility | | $138.04 | $138.04 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,258.93 / $1,380.38
| Professional | | $1,258.93 | $1,258.93 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Facility | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $125.89
| Professional | | $102.33 | $102.33 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $1,445.44 / $2,290.87
| Facility | | $100.00 | $1,445.44 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $79.43 / $109.65
| Facility | | $51.29 | $79.43 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $77.62 / $147.91
| Professional | | $63.10 | $77.62 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $7,762.47 / $7,762.47 / $7,762.47
| Facility | | $7,762.47 | $7,762.47 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8,511.38 / $8,511.38 / $12,022.64
| Professional | | $8,511.38 | $8,511.38 | $12,022.64 |