- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $1,698.24 / $1,698.24
| Facility | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,698.24 / $1,995.26
| Professional | | $891.25 | $1,698.24 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $1,659.59 / $3,019.95
| Facility | | $165.96 | $1,659.59 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $1,348.96 / $3,162.28
| Professional | | $190.55 | $1,348.96 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $501.19 / $524.81
| Facility | | $501.19 | $501.19 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $426.58 / $524.81
| Professional | | $141.25 | $426.58 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $794.33 / $1,862.09
| Facility | | $288.40 | $794.33 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,698.24 / $1,995.26
| Professional | | $891.25 | $1,698.24 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $977.24 / $1,318.26
| Professional | | $100.00 | $977.24 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,288.25 / $1,348.96
| Professional | | $1,288.25 | $1,288.25 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $1,862.09 / $1,905.46
| Professional | | $1,513.56 | $1,862.09 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $1,071.52 / $1,445.44
| Facility | | $117.49 | $1,071.52 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,230.27 / $1,479.11
| Professional | | $891.25 | $1,230.27 | $1,479.11 |