- 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 / $1,000.00 / $1,621.81
| Professional | | $831.76 | $1,000.00 | $1,621.81 |
- 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
- $1,096.48 / $1,096.48 / $2,290.87
| Professional | | $1,096.48 | $1,096.48 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,096.48 / $1,412.54
| Professional | | $1,096.48 | $1,096.48 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,380.38 / $1,380.38
| Facility | | $912.01 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,023.29 / $1,348.96
| Professional | | $1,023.29 | $1,023.29 | $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
- $891.25 / $1,348.96 / $2,041.74
| Professional | | $891.25 | $1,348.96 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $1,348.96 / $2,398.83
| Facility | | $812.83 | $1,348.96 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,096.48 / $2,570.40
| Professional | | $1,096.48 | $1,096.48 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,698.24 / $4,265.80
| Facility | | $1,174.90 | $1,698.24 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,698.24 / $4,265.80
| Professional | | $1,174.90 | $1,698.24 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $933.25 / $2,041.74
| Facility | | $602.56 | $933.25 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,000.00 / $1,659.59
| Professional | | $891.25 | $1,000.00 | $1,659.59 |