- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,344.23 / $2,344.23 / $2,344.23
| Facility | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,479.11 / $2,344.23 / $3,311.31
| Professional | | $1,479.11 | $2,344.23 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $2,691.53 / $4,786.30
| Facility | | $269.15 | $2,691.53 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $2,238.72 / $3,235.94
| Professional | | $302.00 | $2,238.72 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,230.27 / $1,905.46
| Facility | | $1,230.27 | $1,230.27 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $1,047.13 / $1,258.93
| Professional | | $208.93 | $1,047.13 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $1,318.26 / $2,344.23
| Facility | | $288.40 | $1,318.26 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,479.11 / $2,344.23 / $3,311.31
| Professional | | $1,479.11 | $2,344.23 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $213.80 / $2,137.96
| Professional | | $158.49 | $213.80 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $2,137.96 / $2,238.72
| Professional | | $2,137.96 | $2,137.96 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,238.72 / $3,019.95 / $3,019.95
| Professional | | $2,238.72 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $1,000.00 / $1,995.26
| Facility | | $100.00 | $1,000.00 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,258.93 / $1,995.26
| Professional | | $1,174.90 | $1,258.93 | $1,995.26 |