- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $2,630.27 / $2,630.27
| Facility | | $676.08 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $812.83 / $1,122.02
| Professional | | $676.08 | $812.83 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5,011.87 / $8,511.38 / $77,624.71
| Facility | | $5,011.87 | $8,511.38 | $77,624.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $1,659.59 / $1,659.59
| Professional | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $933.25 / $1,513.56
| Facility | | $933.25 | $933.25 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $691.83 / $933.25
| Professional | | $691.83 | $691.83 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $2,187.76 / $3,162.28
| Professional | | $1,548.82 | $2,187.76 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $1,698.24 / $1,698.24
| Facility | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,174.90 / $1,698.24
| Professional | | $1,000.00 | $1,174.90 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $676.08 / $676.08
| Facility | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $831.76 / $1,174.90
| Professional | | $676.08 | $831.76 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $2,344.23 / $3,235.94
| Professional | | $0.60 | $2,344.23 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,548.82
| Facility | | $1,174.90 | $1,174.90 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,584.89
| Professional | | $1,174.90 | $1,174.90 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $2,041.74 / $2,344.23
| Facility | | $741.31 | $2,041.74 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $812.83 / $1,698.24
| Professional | | $630.96 | $812.83 | $1,698.24 |