- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $912.01 / $912.01
| Facility | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,023.29 / $1,380.38
| Professional | | $912.01 | $1,023.29 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $1,862.09 / $2,630.27
| Facility | | $1,737.80 | $1,862.09 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,412.54 / $2,454.71
| Professional | | $1,318.26 | $1,412.54 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $1,096.48 / $1,737.80
| Facility | | $128.82 | $1,096.48 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $1,096.48 / $2,089.30
| Professional | | $109.65 | $1,096.48 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $1,174.90
| Facility | | $1,122.02 | $1,122.02 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $954.99 / $1,380.38
| Professional | | $954.99 | $954.99 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $1,122.02
| Facility | | $1,122.02 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,122.02 / $1,202.26
| Professional | | $954.99 | $1,122.02 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $239.88 / $1,737.80
| Professional | | $93.33 | $239.88 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $2,238.72 / $3,090.30
| Professional | | $1,819.70 | $2,238.72 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $588.84 / $1,230.27
| Facility | | $74.13 | $588.84 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $851.14 / $1,318.26
| Professional | | $575.44 | $851.14 | $1,318.26 |