- 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
- $645.65 / $891.25 / $1,230.27
| Professional | | $645.65 | $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
- $1,548.82 / $1,698.24 / $2,041.74
| Professional | | $1,548.82 | $1,698.24 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $4,168.69 / $8,912.51
| Facility | | $891.25 | $4,168.69 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $2,570.40 / $3,467.37
| Professional | | $645.65 | $2,570.40 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,479.11 / $2,238.72
| Facility | | $870.96 | $1,479.11 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $2,137.96 / $2,630.27
| Professional | | $1,621.81 | $2,137.96 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,778.28 / $7,413.10
| Facility | | $891.25 | $1,778.28 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $891.25 / $1,949.84
| Professional | | $707.95 | $891.25 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $70.79 / $1,202.26
| Professional | | $54.95 | $70.79 | $1,202.26 |
- 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 / $4,466.84
| Professional | | $1,819.70 | $2,691.53 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $3,630.78 / $8,317.64
| Facility | | $891.25 | $3,630.78 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $1,288.25 / $8,317.64
| Professional | | $645.65 | $1,288.25 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $831.76 / $1,819.70
| Facility | | $549.54 | $831.76 | $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 |