- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,000.00 / $1,174.90
| Facility | | $1,000.00 | $1,000.00 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $831.76 / $1,318.26
| Professional | | $630.96 | $831.76 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $891.25 / $1,778.28
| Facility | | $891.25 | $891.25 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,862.09 / $2,290.87
| Professional | | $891.25 | $1,862.09 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,513.56 / $1,584.89
| Professional | | $1,348.96 | $1,513.56 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,905.46 / $7,585.78
| Facility | | $1,096.48 | $1,905.46 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $977.24 / $2,691.53
| Professional | | $724.44 | $977.24 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $1,819.70 / $2,187.76
| Professional | | $1,737.80 | $1,819.70 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,778.28 / $1,778.28
| Facility | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $2,691.53 / $2,691.53
| Professional | | $1,659.59 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $1,621.81 / $3,801.89
| Facility | | $549.54 | $1,621.81 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $794.33 / $1,513.56
| Professional | | $707.95 | $794.33 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,513.56 / $1,513.56
| Professional | | $1,202.26 | $1,513.56 | $1,513.56 |