- 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
- $602.56 / $1,096.48 / $1,584.89
| Professional | | $602.56 | $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
- $123.03 / $1,047.13 / $1,445.44
| Professional | | $123.03 | $1,047.13 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $346.74 / $363.08
| Facility | | $346.74 | $346.74 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $295.12 / $346.74
| Professional | | $100.00 | $295.12 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $616.60 / $1,174.90
| Facility | | $144.54 | $616.60 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $1,096.48 / $1,584.89
| Professional | | $602.56 | $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 / $933.25
| Facility | | $47.86 | $416.87 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $562.34 / $870.96
| Professional | | $478.63 | $562.34 | $870.96 |