- 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
- $562.34 / $724.44 / $1,096.48
| Professional | | $562.34 | $724.44 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $758.58 / $758.58
| Facility | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $549.54 / $549.54
| Professional | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $2,691.53 / $3,235.94
| Professional | | $1,122.02 | $2,691.53 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,122.02 / $1,513.56
| Facility | | $891.25 | $1,122.02 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,202.26 / $1,659.59
| Professional | | $1,096.48 | $1,202.26 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,445.44 / $1,479.11
| Facility | | $1,174.90 | $1,445.44 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,318.26 / $1,621.81
| Professional | | $1,202.26 | $1,318.26 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $1,230.27 / $1,659.59
| Facility | | $707.95 | $1,230.27 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $1,258.93 / $1,548.82
| Professional | | $79.43 | $1,258.93 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $2,344.23 / $5,754.40
| Facility | | $1,230.27 | $2,344.23 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,479.11 / $1,659.59 / $1,659.59
| Professional | | $1,479.11 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $812.83 / $1,995.26
| Facility | | $562.34 | $812.83 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $602.56 / $1,148.15
| Professional | | $489.78 | $602.56 | $1,148.15 |