- 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 / $1,380.38
| Professional | | $630.96 | $870.96 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,778.28 / $2,951.21
| Facility | | $1,778.28 | $1,778.28 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,659.59 / $1,995.26
| Professional | | $1,584.89 | $1,659.59 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $4,073.80 / $8,709.64
| Facility | | $891.25 | $4,073.80 | $8,709.64 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $2,511.89 / $3,388.44
| Professional | | $660.69 | $2,511.89 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,445.44 / $2,187.76
| Facility | | $870.96 | $1,445.44 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,737.80 / $2,137.96
| Professional | | $1,000.00 | $1,737.80 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,737.80 / $7,585.78
| Facility | | $870.96 | $1,737.80 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,047.13 / $1,949.84
| Professional | | $794.33 | $1,047.13 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $70.79 / $1,023.29
| Professional | | $54.95 | $70.79 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,818.38 / $2,818.38 / $2,818.38
| Facility | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,995.26 / $3,467.37
| Professional | | $1,258.93 | $1,995.26 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $2,691.53 / $4,466.84
| Professional | | $1,778.28 | $2,691.53 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $3,548.13 / $8,317.64
| Facility | | $891.25 | $3,548.13 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $1,318.26 / $8,709.64
| Professional | | $660.69 | $1,318.26 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,071.52 / $1,778.28
| Facility | | $870.96 | $1,071.52 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $870.96 / $1,445.44
| Professional | | $645.65 | $870.96 | $1,445.44 |