- 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 / $1,698.24
| Professional | | $831.76 | $1,000.00 | $1,698.24 |
- 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
- $1,122.02 / $1,122.02 / $2,344.23
| Professional | | $1,122.02 | $1,122.02 | $2,344.23 |
- 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
- $851.14 / $1,174.90 / $1,174.90
| Facility | | $851.14 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $851.14 / $1,174.90
| Professional | | $851.14 | $851.14 | $1,174.90 |
- 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
- $933.25 / $1,348.96 / $2,041.74
| Professional | | $933.25 | $1,348.96 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,318.26 / $2,511.89
| Facility | | $831.76 | $1,318.26 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,348.96 / $2,570.40
| Professional | | $1,096.48 | $1,348.96 | $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
- $630.96 / $977.24 / $2,041.74
| Facility | | $630.96 | $977.24 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,000.00 / $1,659.59
| Professional | | $912.01 | $1,000.00 | $1,659.59 |