- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,023.29 / $1,023.29
| Facility | | $1,023.29 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $1,023.29 / $7,943.28
| Professional | | $512.86 | $1,023.29 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $1,548.82 / $1,584.89
| Professional | | $1,412.54 | $1,548.82 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,000.00 / $1,819.70
| Facility | | $1,000.00 | $1,000.00 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,862.09 / $3,090.30
| Professional | | $1,000.00 | $1,862.09 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,819.70 / $8,317.64
| Facility | | $1,023.29 | $1,819.70 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $812.83 / $1,621.81
| Professional | | $537.03 | $812.83 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,778.28 / $4,365.16
| Professional | | $1,778.28 | $1,778.28 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $1,819.70 / $1,819.70
| Facility | | $1,819.70 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,238.72 / $3,981.07 / $4,365.16
| Professional | | $2,238.72 | $3,981.07 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $933.25 / $1,862.09
| Facility | | $616.60 | $933.25 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $812.83 / $1,258.93
| Professional | | $588.84 | $812.83 | $1,258.93 |