- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $891.25 / $891.25
| Facility | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $891.25 / $891.25
| Professional | | $676.08 | $891.25 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $2,511.89 / $2,511.89
| Facility | | $1,380.38 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,380.38 / $1,737.80
| Professional | | $1,023.29 | $1,380.38 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $831.76 / $5,623.41
| Facility | | $831.76 | $831.76 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $1,698.24 / $2,691.53
| Professional | | $707.95 | $1,698.24 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,148.15 / $1,621.81
| Facility | | $776.25 | $1,148.15 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $912.01 / $912.01
| Professional | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,348.96 / $7,079.46
| Facility | | $776.25 | $1,348.96 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $776.25 / $1,288.25
| Professional | | $660.69 | $776.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $104.71 / $1,122.02
| Professional | | $54.95 | $104.71 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $1,000.00 / $1,047.13
| Professional | | $676.08 | $1,000.00 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $309.03 / $346.74
| Professional | | $154.88 | $309.03 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $2,511.89 / $7,413.10
| Facility | | $831.76 | $2,511.89 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $831.76 / $851.14
| Professional | | $107.15 | $831.76 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $512.86 / $1,047.13
| Facility | | $63.10 | $512.86 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $758.58 / $1,380.38
| Professional | | $524.81 | $758.58 | $1,380.38 |