- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $1,380.38 / $1,621.81
| Professional | | $1,380.38 | $1,380.38 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $245.47 / $302.00
| Facility | | $190.55 | $245.47 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $2,089.30 / $2,630.27
| Professional | | $1,348.96 | $2,089.30 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $1,380.38 / $2,137.96
| Professional | | $199.53 | $1,380.38 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $2,041.74 / $3,019.95
| Facility | | $1,698.24 | $2,041.74 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $1,698.24 / $3,019.95
| Professional | | $1,698.24 | $1,698.24 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $1,949.84 / $2,041.74
| Professional | | $1,949.84 | $1,949.84 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $245.47 / $302.00
| Facility | | $204.17 | $245.47 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.62 / $1,621.81 / $2,630.27
| Facility | | $1.62 | $1,621.81 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $1,621.81
| Professional | | $125.89 | $125.89 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $1,380.38 / $1,380.38
| Professional | | $1,380.38 | $1,380.38 | $1,380.38 |