- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $1,096.48 / $1,584.89
| Professional | | $630.96 | $1,096.48 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $1,288.25 / $2,290.87
| Facility | | $128.82 | $1,288.25 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $1,047.13 / $1,513.56
| Professional | | $128.82 | $1,047.13 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,000.00 / $1,047.13
| Facility | | $1,000.00 | $1,000.00 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $851.14 / $1,000.00
| Professional | | $109.65 | $851.14 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $616.60 / $1,096.48
| Facility | | $138.04 | $616.60 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $1,096.48 / $1,584.89
| Professional | | $630.96 | $1,096.48 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $100.00 / $1,023.29
| Professional | | $75.86 | $100.00 | $1,023.29 |
- 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
- $1,071.52 / $1,445.44 / $1,445.44
| Professional | | $1,071.52 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $416.87 / $954.99
| Facility | | $47.86 | $416.87 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $562.34 / $891.25
| Professional | | $478.63 | $562.34 | $891.25 |