- 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
- $467.74 / $851.14 / $1,023.29
| Professional | | $467.74 | $851.14 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Professional | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $114.82 / $288.40
| Facility | | $89.13 | $114.82 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $1,023.29 / $3,162.28
| Professional | | $707.95 | $1,023.29 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $208.93 / $457.09
| Facility | | $95.50 | $208.93 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $851.14 / $1,348.96
| Professional | | $537.03 | $851.14 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Facility | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $776.25 / $776.25
| Professional | | $776.25 | $776.25 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $630.96 / $1,905.46
| Professional | | $128.82 | $630.96 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,786.30 / $4,897.79 / $4,897.79
| Facility | | $4,786.30 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,786.30 / $7,762.47 / $7,762.47
| Professional | | $4,786.30 | $7,762.47 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $54.95 / $70.79
| Professional | | $54.95 | $54.95 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $831.76 / $1,698.24
| Facility | | $95.50 | $831.76 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $776.25 / $776.25
| Professional | | $95.50 | $776.25 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $87.10 / $2,041.74
| Facility | | $51.29 | $87.10 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $125.89 / $912.01
| Professional | | $51.29 | $125.89 | $912.01 |