- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,023.29 / $1,023.29
| Facility | | $1,023.29 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,023.29 / $1,288.25
| Professional | | $776.25 | $1,023.29 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $2,290.87 / $2,691.53
| Facility | | $194.98 | $2,290.87 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $131.83
| Professional | | $123.03 | $123.03 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $363.08 / $380.19
| Facility | | $363.08 | $363.08 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $363.08
| Professional | | $309.03 | $309.03 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $776.25 / $1,288.25
| Facility | | $478.63 | $776.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,023.29 / $1,288.25
| Professional | | $776.25 | $1,023.29 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $977.24
| Professional | | $93.33 | $93.33 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $2,344.23 / $2,691.53
| Facility | | $2,290.87 | $2,344.23 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,995.26 / $1,995.26 / $2,454.71
| Professional | | $1,995.26 | $1,995.26 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $588.84 / $1,148.15
| Facility | | $57.54 | $588.84 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $724.44 / $1,148.15
| Professional | | $691.83 | $724.44 | $1,148.15 |