- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,258.93 / $1,258.93
| Facility | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $1,258.93 / $1,479.11
| Professional | | $660.69 | $1,258.93 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $1,230.27 / $2,290.87
| Facility | | $123.03 | $1,230.27 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $1,000.00 / $1,584.89
| Professional | | $138.04 | $1,000.00 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $870.96 / $1,047.13
| Facility | | $870.96 | $870.96 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $741.31 / $891.25
| Professional | | $104.71 | $741.31 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $645.65 / $1,258.93
| Facility | | $138.04 | $645.65 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $1,258.93 / $1,479.11
| Professional | | $660.69 | $1,258.93 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $724.44 / $977.24
| Professional | | $74.13 | $724.44 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $933.25 / $1,000.00
| Professional | | $933.25 | $933.25 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,348.96 / $1,412.54
| Professional | | $1,122.02 | $1,348.96 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $562.34 / $1,047.13
| Facility | | $57.54 | $562.34 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $691.83 / $1,047.13
| Professional | | $645.65 | $691.83 | $1,047.13 |