- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $891.25 / $891.25
| Facility | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $891.25 / $1,230.27
| Professional | | $707.95 | $891.25 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $1,819.70 / $3,019.95
| Facility | | $1,819.70 | $1,819.70 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $1,698.24 / $2,041.74
| Professional | | $1,698.24 | $1,698.24 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $4,168.69 / $8,912.51
| Facility | | $1,148.15 | $4,168.69 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $2,570.40 / $3,467.37
| Professional | | $831.76 | $2,570.40 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,479.11 / $2,238.72
| Facility | | $891.25 | $1,479.11 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,778.28 / $2,137.96
| Professional | | $1,023.29 | $1,778.28 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,778.28 / $7,943.28
| Facility | | $891.25 | $1,778.28 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $891.25 / $1,995.26
| Professional | | $741.31 | $891.25 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $70.79 / $758.58
| Professional | | $54.95 | $70.79 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $2,041.74 / $3,548.13
| Professional | | $1,288.25 | $2,041.74 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $2,691.53 / $4,677.35
| Professional | | $1,819.70 | $2,691.53 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $3,630.78 / $9,332.54
| Facility | | $1,148.15 | $3,630.78 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,659.59 / $13,489.63
| Professional | | $831.76 | $1,659.59 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $870.96 / $1,819.70
| Facility | | $575.44 | $870.96 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $891.25 / $1,479.11
| Professional | | $588.84 | $891.25 | $1,479.11 |