- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $2,089.30 / $2,089.30
| Facility | | $776.25 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $2,089.30 / $2,238.72
| Professional | | $707.95 | $2,089.30 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $2,630.27 / $6,606.93
| Facility | | $2,089.30 | $2,630.27 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $2,089.30 / $3,388.44
| Professional | | $457.09 | $2,089.30 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $39.81 / $39.81
| Professional | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $218.78 / $295.12
| Facility | | $131.83 | $218.78 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $154.88
| Professional | | $125.89 | $125.89 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $2,089.30 / $2,818.38
| Professional | | $177.83 | $2,089.30 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $173.78 / $269.15
| Professional | | $131.83 | $173.78 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12,589.25 / $13,182.57 / $13,182.57
| Professional | | $12,589.25 | $13,182.57 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $194.98
| Professional | | $177.83 | $177.83 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $2,089.30 / $3,311.31
| Facility | | $173.78 | $2,089.30 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $3,311.31
| Professional | | $125.89 | $125.89 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $194.98 / $263.03
| Professional | | $147.91 | $194.98 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,230.27 / $1,230.27
| Facility | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $407.38
| Professional | | $125.89 | $125.89 | $407.38 |