- 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 / $870.96 / $1,445.44
| Professional | | $630.96 | $870.96 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $870.96 / $870.96
| Professional | | $870.96 | $870.96 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $3,162.28 / $3,890.45
| Professional | | $1,096.48 | $3,162.28 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,096.48 / $1,548.82
| Facility | | $870.96 | $1,096.48 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,148.15 / $1,621.81
| Professional | | $1,071.52 | $1,148.15 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,412.54 / $1,862.09
| Facility | | $1,148.15 | $1,412.54 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,445.44 / $1,905.46
| Professional | | $1,445.44 | $1,445.44 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,258.93 / $1,949.84
| Facility | | $870.96 | $1,258.93 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $1,258.93 / $1,513.56
| Professional | | $79.43 | $1,258.93 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $2,290.87 / $5,623.41
| Facility | | $1,202.26 | $2,290.87 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,621.81 / $1,621.81
| Professional | | $1,445.44 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $1,071.52 / $2,344.23
| Facility | | $549.54 | $1,071.52 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $724.44 / $1,380.38
| Professional | | $562.34 | $724.44 | $1,380.38 |