- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $3,235.94 / $3,235.94
| Facility | | $831.76 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,122.02 / $1,659.59
| Professional | | $831.76 | $1,122.02 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5,011.87 / $8,511.38 / $77,624.71
| Facility | | $5,011.87 | $8,511.38 | $77,624.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,659.59 / $2,041.74
| Professional | | $1,122.02 | $1,659.59 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,548.82 / $2,041.74
| Facility | | $1,548.82 | $1,548.82 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $1,548.82
| Professional | | $1,122.02 | $1,122.02 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $2,691.53 / $3,890.45
| Professional | | $1,905.46 | $2,691.53 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,445.44 / $2,041.74
| Professional | | $1,230.27 | $1,445.44 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $831.76 / $831.76
| Facility | | $831.76 | $831.76 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,122.02 / $1,659.59
| Professional | | $831.76 | $1,122.02 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $2,754.23 / $3,981.07
| Professional | | $0.60 | $2,754.23 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,445.44 / $1,905.46
| Facility | | $1,445.44 | $1,445.44 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,445.44 / $2,290.87
| Professional | | $1,445.44 | $1,445.44 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $2,754.23 / $3,162.28
| Facility | | $1,000.00 | $2,754.23 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,000.00 / $2,041.74
| Professional | | $794.33 | $1,000.00 | $2,041.74 |