- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,000.00 / $2,570.40
| Facility | | $831.76 | $1,000.00 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,122.02 / $1,995.26
| Professional | | $831.76 | $1,122.02 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $2,041.74 / $2,187.76
| Facility | | $2,041.74 | $2,041.74 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,230.27 / $2,570.40
| Professional | | $1,230.27 | $1,230.27 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,071.52 / $1,412.54
| Professional | | $1,071.52 | $1,071.52 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,548.82 / $1,548.82
| Facility | | $1,000.00 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $1,348.96
| Professional | | $1,122.02 | $1,122.02 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $2,041.74 / $2,884.03
| Professional | | $1,548.82 | $2,041.74 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,348.96 / $2,041.74
| Professional | | $1,258.93 | $1,348.96 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,380.38 / $2,570.40
| Facility | | $831.76 | $1,380.38 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,202.26 / $2,570.40
| Professional | | $1,096.48 | $1,202.26 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,659.59 / $4,265.80
| Facility | | $1,174.90 | $1,659.59 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,659.59 / $4,265.80
| Professional | | $1,174.90 | $1,659.59 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $1,071.52 / $2,041.74
| Facility | | $676.08 | $1,071.52 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,000.00 / $1,659.59
| Professional | | $933.25 | $1,000.00 | $1,659.59 |