- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $912.01 / $912.01
| Facility | | $912.01 | $912.01 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $812.83 / $1,122.02
| Professional | | $588.84 | $812.83 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $870.96 / $870.96
| Facility | | $870.96 | $870.96 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $630.96 / $630.96
| Professional | | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $3,019.95 / $3,630.78
| Professional | | $1,148.15 | $3,019.95 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,148.15 / $1,621.81
| Facility | | $912.01 | $1,148.15 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,230.27 / $1,659.59
| Professional | | $1,122.02 | $1,230.27 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,479.11 / $1,737.80
| Facility | | $1,202.26 | $1,479.11 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,513.56 / $1,778.28
| Professional | | $1,202.26 | $1,513.56 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $1,258.93 / $1,905.46
| Facility | | $812.83 | $1,258.93 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $1,318.26 / $1,621.81
| Professional | | $79.43 | $1,318.26 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $2,398.83 / $5,888.44
| Facility | | $1,258.93 | $2,398.83 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,698.24 / $1,698.24
| Professional | | $1,548.82 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,023.29 / $2,187.76
| Facility | | $891.25 | $1,023.29 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $676.08 / $1,288.25
| Professional | | $524.81 | $676.08 | $1,288.25 |