- 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
- $407.38 / $891.25 / $7,413.10
| Professional | | $407.38 | $891.25 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,348.96 / $1,380.38
| Professional | | $1,230.27 | $1,348.96 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,047.13 / $1,584.89
| Facility | | $1,047.13 | $1,047.13 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,737.80 / $2,454.71
| Professional | | $1,047.13 | $1,737.80 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,548.82 / $6,760.83
| Facility | | $891.25 | $1,548.82 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $691.83 / $1,412.54
| Professional | | $467.74 | $691.83 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,548.82 / $3,801.89
| Professional | | $1,548.82 | $1,548.82 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,584.89 / $1,584.89
| Facility | | $1,584.89 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $3,467.37 / $3,801.89
| Professional | | $1,949.84 | $3,467.37 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $758.58 / $1,479.11
| Facility | | $489.78 | $758.58 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $691.83 / $1,047.13
| Professional | | $501.19 | $691.83 | $1,047.13 |