- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $954.99 / $954.99
| Facility | | $954.99 | $954.99 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,023.29 / $1,348.96
| Professional | | $891.25 | $1,023.29 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,548.82 / $1,548.82
| Facility | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,778.28 / $2,041.74
| Professional | | $1,348.96 | $1,778.28 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $1,445.44
| Facility | | $1,122.02 | $1,122.02 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $954.99 / $1,122.02
| Professional | | $338.84 | $954.99 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $107.15 / $1,047.13
| Professional | | $64.57 | $107.15 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $2,754.23 / $3,630.78
| Facility | | $177.83 | $2,754.23 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $2,754.23
| Professional | | $177.83 | $177.83 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $169.82 / $1,698.24
| Facility | | $147.91 | $169.82 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $204.17 / $1,698.24
| Professional | | $147.91 | $204.17 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $1,778.28 / $2,041.74
| Professional | | $199.53 | $1,778.28 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $691.83 / $1,348.96
| Facility | | $93.33 | $691.83 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $891.25 / $1,479.11
| Professional | | $812.83 | $891.25 | $1,479.11 |
- 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 |