- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,174.90
| Facility | | $1,174.90 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,288.25
| Professional | | $1,174.90 | $1,174.90 | $1,288.25 |
- 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
- $181.97 / $1,071.52 / $1,348.96
| Professional | | $181.97 | $1,071.52 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $501.19 / $1,174.90
| Professional | | $263.03 | $501.19 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $1,318.26 / $2,041.74
| Facility | | $218.78 | $1,318.26 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,174.90 / $2,041.74
| Professional | | $1,096.48 | $1,174.90 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $1,318.26 / $1,445.44
| Professional | | $131.83 | $1,318.26 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $245.47 / $302.00
| Facility | | $204.17 | $245.47 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $346.74 / $346.74
| Professional | | $147.91 | $346.74 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.20 / $1,202.26 / $1,949.84
| Facility | | $1.20 | $1,202.26 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $1,202.26
| Professional | | $125.89 | $125.89 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,174.90
| Facility | | $1,174.90 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,174.90
| Professional | | $1,174.90 | $1,174.90 | $1,174.90 |