- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $776.25 / $776.25
| Facility | | $776.25 | $776.25 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $794.33 / $1,318.26
| Professional | | $776.25 | $794.33 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $794.33 / $4,168.69
| Professional | | $794.33 | $794.33 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $2,511.89 / $4,265.80
| Facility | | $1,096.48 | $2,511.89 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $1,445.44 / $1,949.84
| Professional | | $812.83 | $1,445.44 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $1,148.15 / $2,454.71
| Facility | | $56.23 | $1,148.15 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $30.90 / $1,698.24
| Professional | | $30.90 | $30.90 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $831.76 / $2,454.71
| Facility | | $56.23 | $831.76 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $794.33 / $1,288.25
| Professional | | $794.33 | $794.33 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $64.57 / $85.11
| Professional | | $64.57 | $64.57 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $1,122.02 / $2,041.74
| Facility | | $131.83 | $1,122.02 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $117.49 / $4,168.69
| Professional | | $60.26 | $117.49 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $14,125.38
| Facility | | $812.83 | $812.83 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $812.83
| Professional | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,548.82 / $3,311.31
| Professional | | $1,548.82 | $1,548.82 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $891.25 / $2,089.30
| Facility | | $891.25 | $891.25 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $794.33 / $1,288.25
| Professional | | $794.33 | $794.33 | $1,288.25 |