- 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
- $575.44 / $831.76 / $1,122.02
| Professional | | $575.44 | $831.76 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $1,348.96
| Facility | | $1,122.02 | $1,122.02 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,047.13 / $1,122.02
| Professional | | $1,047.13 | $1,047.13 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $691.83 / $831.76
| Professional | | $691.83 | $691.83 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $645.65 / $870.96
| Professional | | $602.56 | $645.65 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $1,122.02 / $1,949.84
| Facility | | $588.84 | $1,122.02 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $977.24 / $1,122.02
| Facility | | $537.03 | $977.24 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $691.83 / $1,000.00
| Professional | | $537.03 | $691.83 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $6,025.60 / $6,025.60 / $6,025.60
| Facility | | $6,025.60 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8,511.38 / $8,511.38 / $12,882.50
| Professional | | $8,511.38 | $8,511.38 | $12,882.50 |