- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $794.33 / $794.33
| Facility | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $794.33 / $794.33
| Professional | | $588.84 | $794.33 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $2,238.72 / $2,238.72
| Facility | | $1,230.27 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,230.27 / $1,698.24
| Professional | | $912.01 | $1,230.27 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $398.11 / $5,623.41
| Facility | | $398.11 | $398.11 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $1,412.54 / $2,344.23
| Professional | | $338.84 | $1,412.54 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,023.29 / $1,479.11
| Facility | | $794.33 | $1,023.29 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,479.11 / $5,495.41
| Facility | | $794.33 | $1,479.11 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $645.65 / $1,148.15
| Professional | | $512.86 | $645.65 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $64.57 / $309.03
| Professional | | $50.12 | $64.57 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $1,122.02 / $2,089.30
| Professional | | $630.96 | $1,122.02 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $257.04 / $346.74
| Professional | | $162.18 | $257.04 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $2,398.83 / $5,495.41
| Facility | | $64.57 | $2,398.83 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $398.11 / $407.38
| Professional | | $288.40 | $398.11 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $398.11 / $870.96
| Facility | | $51.29 | $398.11 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $630.96 / $1,174.90
| Professional | | $457.09 | $630.96 | $1,174.90 |