- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,659.59 / $2,344.23
| Professional | | $1,047.13 | $1,659.59 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $1,905.46 / $3,388.44
| Facility | | $190.55 | $1,905.46 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $1,584.89 / $2,238.72
| Professional | | $213.80 | $1,584.89 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $398.11 / $416.87
| Facility | | $398.11 | $398.11 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $338.84 / $398.11
| Professional | | $147.91 | $338.84 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $1,000.00 / $1,737.80
| Facility | | $213.80 | $1,000.00 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,659.59 / $2,344.23
| Professional | | $1,047.13 | $1,659.59 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $147.91 / $1,513.56
| Professional | | $112.20 | $147.91 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,479.11 / $1,479.11 / $1,584.89
| Professional | | $1,479.11 | $1,479.11 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $2,137.96 / $2,137.96
| Professional | | $1,584.89 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $616.60 / $1,412.54
| Facility | | $70.79 | $616.60 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $831.76 / $1,318.26
| Professional | | $707.95 | $831.76 | $1,318.26 |