- 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
- $537.03 / $891.25 / $891.25
| Professional | | $537.03 | $891.25 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $2,454.71 / $2,454.71
| Facility | | $1,348.96 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,348.96 / $1,698.24
| Professional | | $1,047.13 | $1,348.96 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $870.96 / $5,370.32
| Facility | | $870.96 | $870.96 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $1,659.59 / $2,630.27
| Professional | | $741.31 | $1,659.59 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $1,047.13 / $1,584.89
| Facility | | $446.68 | $1,047.13 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $933.25 / $933.25
| Professional | | $933.25 | $933.25 | $933.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $1,318.26 / $7,244.36
| Facility | | $446.68 | $1,318.26 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $794.33 / $1,288.25
| Professional | | $660.69 | $794.33 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $77.62 / $1,071.52
| Professional | | $50.12 | $77.62 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,023.29 / $1,071.52
| Professional | | $691.83 | $1,023.29 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $309.03 / $354.81
| Professional | | $151.36 | $309.03 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $2,570.40 / $7,413.10
| Facility | | $870.96 | $2,570.40 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $870.96 / $870.96
| Professional | | $104.71 | $870.96 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $512.86 / $1,047.13
| Facility | | $64.57 | $512.86 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $776.25 / $1,380.38
| Professional | | $512.86 | $776.25 | $1,380.38 |