- 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
- $371.54 / $870.96 / $6,606.93
| Professional | | $371.54 | $870.96 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,318.26 / $1,318.26
| Professional | | $1,202.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $1,513.56
| Facility | | $812.83 | $812.83 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $1,479.11 / $2,290.87
| Professional | | $812.83 | $1,479.11 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,479.11 / $6,165.95
| Facility | | $831.76 | $1,479.11 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $758.58 / $1,348.96
| Professional | | $457.09 | $758.58 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,479.11 / $1,513.56 / $3,630.78
| Professional | | $1,479.11 | $1,513.56 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $1,513.56 / $1,513.56
| Facility | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $3,388.44 / $3,630.78
| Professional | | $1,905.46 | $3,388.44 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $870.96 / $1,318.26
| Facility | | $758.58 | $870.96 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $676.08 / $1,071.52
| Professional | | $489.78 | $676.08 | $1,071.52 |