- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $1,000.00 / $2,570.40
| Facility | | $812.83 | $1,000.00 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $1,000.00 / $1,995.26
| Professional | | $812.83 | $1,000.00 | $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
- $1,148.15 / $1,148.15 / $2,398.83
| Professional | | $1,148.15 | $1,148.15 | $2,398.83 |
- 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
- $794.33 / $1,174.90 / $1,174.90
| Facility | | $794.33 | $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
- $954.99 / $1,348.96 / $1,995.26
| Professional | | $954.99 | $1,348.96 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $1,318.26 / $2,570.40
| Facility | | $812.83 | $1,318.26 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,318.26 / $2,570.40
| Professional | | $1,096.48 | $1,318.26 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,659.59 / $4,265.80
| Facility | | $1,148.15 | $1,659.59 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,659.59 / $4,265.80
| Professional | | $1,148.15 | $1,659.59 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $933.25 / $2,041.74
| Facility | | $645.65 | $933.25 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,000.00 / $1,621.81
| Professional | | $933.25 | $1,000.00 | $1,621.81 |