- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,778.28 / $1,778.28
| Facility | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,778.28 / $2,570.40
| Professional | | $1,148.15 | $1,778.28 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $2,089.30 / $3,715.35
| Facility | | $208.93 | $2,089.30 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $1,698.24 / $2,454.71
| Professional | | $234.42 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,071.52 / $1,479.11
| Facility | | $1,071.52 | $1,071.52 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $912.01 / $1,122.02
| Professional | | $162.18 | $912.01 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $1,000.00 / $1,778.28
| Facility | | $223.87 | $1,000.00 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $1,778.28 / $2,570.40
| Professional | | $630.96 | $1,778.28 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $162.18 / $1,659.59
| Professional | | $123.03 | $162.18 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,621.81 / $1,698.24
| Professional | | $1,621.81 | $1,621.81 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $2,344.23 / $2,344.23
| Professional | | $1,737.80 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $776.25 / $1,513.56
| Facility | | $77.62 | $776.25 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $954.99 / $1,513.56
| Professional | | $891.25 | $954.99 | $1,513.56 |