- 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
- $707.95 / $1,288.25 / $1,548.82
| Professional | | $707.95 | $1,288.25 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $1,258.93 / $2,454.71
| Facility | | $125.89 | $1,258.93 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $1,047.13 / $1,621.81
| Professional | | $141.25 | $1,047.13 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $602.56 / $1,047.13
| Facility | | $602.56 | $602.56 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $512.86 / $630.96
| Professional | | $112.20 | $512.86 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $707.95 / $1,445.44
| Facility | | $134.90 | $707.95 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $1,288.25 / $1,548.82
| Professional | | $707.95 | $1,288.25 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $741.31 / $1,000.00
| Professional | | $75.86 | $741.31 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,000.00 / $1,047.13
| Professional | | $1,000.00 | $1,000.00 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,445.44 / $1,445.44
| Professional | | $1,047.13 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $562.34 / $1,096.48
| Facility | | $58.88 | $562.34 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $707.95 / $1,096.48
| Professional | | $645.65 | $707.95 | $1,096.48 |