- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $851.14 / $851.14
| Facility | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $851.14 / $1,584.89
| Professional | | $676.08 | $851.14 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $2,951.21 / $3,090.30
| Facility | | $295.12 | $2,951.21 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $812.83 / $2,041.74
| Professional | | $194.98 | $812.83 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $851.14
| Facility | | $812.83 | $812.83 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $691.83 / $831.76
| Professional | | $93.33 | $691.83 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $851.14 / $1,584.89
| Facility | | $141.25 | $851.14 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $851.14 / $1,584.89
| Professional | | $676.08 | $851.14 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $128.82 / $1,318.26
| Professional | | $97.72 | $128.82 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $776.25 / $812.83
| Professional | | $776.25 | $776.25 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $1,862.09
| Professional | | $1,122.02 | $1,122.02 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $524.81 / $794.33
| Facility | | $66.07 | $524.81 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $602.56 / $794.33
| Professional | | $501.19 | $602.56 | $794.33 |