- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,445.44 / $1,445.44
| Facility | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,445.44 / $1,737.80
| Professional | | $1,445.44 | $1,445.44 | $1,737.80 |
- 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
- $269.15 / $1,905.46 / $2,238.72
| Professional | | $269.15 | $1,905.46 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $1,445.44 / $2,238.72
| Professional | | $199.53 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $2,089.30 / $3,548.13
| Facility | | $1,737.80 | $2,089.30 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $1,737.80 / $3,019.95
| Professional | | $1,737.80 | $1,737.80 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $2,041.74 / $2,187.76
| Professional | | $302.00 | $2,041.74 | $2,187.76 |
- 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
- $302.00 / $302.00 / $2,344.23
| Professional | | $302.00 | $302.00 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.62 / $1,659.59 / $2,691.53
| Facility | | $1.62 | $1,659.59 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $1,659.59
| Professional | | $125.89 | $125.89 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,445.44 / $1,445.44
| Facility | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,445.44 / $1,445.44
| Professional | | $1,445.44 | $1,445.44 | $1,445.44 |