- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $933.25 / $933.25
| Facility | | $933.25 | $933.25 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $933.25 / $6,309.57
| Professional | | $354.81 | $933.25 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,412.54 / $1,412.54
| Professional | | $1,288.25 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $724.44 / $1,621.81
| Facility | | $724.44 | $724.44 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $1,584.89 / $2,454.71
| Professional | | $724.44 | $1,584.89 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,584.89 / $5,754.40
| Facility | | $831.76 | $1,584.89 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $724.44 / $1,445.44
| Professional | | $489.78 | $724.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,621.81 / $3,890.45
| Professional | | $1,584.89 | $1,621.81 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $3,630.78 / $3,890.45
| Professional | | $2,041.74 | $3,630.78 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $812.83 / $1,258.93
| Facility | | $645.65 | $812.83 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $724.44 / $1,122.02
| Professional | | $489.78 | $724.44 | $1,122.02 |