- 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
- $691.83 / $891.25 / $1,479.11
| Professional | | $691.83 | $891.25 | $1,479.11 |
- 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
- $954.99 / $4,168.69 / $8,912.51
| Facility | | $954.99 | $4,168.69 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $2,570.40 / $3,467.37
| Professional | | $707.95 | $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 / $2,187.76
| Professional | | $1,023.29 | $1,778.28 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,778.28 / $8,317.64
| Facility | | $891.25 | $1,778.28 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,096.48 / $2,041.74
| Professional | | $794.33 | $1,096.48 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $70.79 / $1,047.13
| Professional | | $54.95 | $70.79 | $1,047.13 |
- 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 / $2,754.23 / $4,897.79
| Professional | | $1,819.70 | $2,754.23 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $3,630.78 / $9,772.37
| Facility | | $954.99 | $3,630.78 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $1,412.54 / $10,000.00
| Professional | | $707.95 | $1,412.54 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,148.15 / $1,819.70
| Facility | | $912.01 | $1,148.15 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $933.25 / $1,513.56
| Professional | | $691.83 | $933.25 | $1,513.56 |