- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $776.25 / $776.25
| Facility | | $776.25 | $776.25 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $776.25 / $1,288.25
| Professional | | $645.65 | $776.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,548.82 / $2,570.40
| Facility | | $1,548.82 | $1,548.82 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,445.44 / $1,737.80
| Professional | | $1,445.44 | $1,445.44 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $3,630.78 / $7,762.47
| Facility | | $851.14 | $3,630.78 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $2,238.72 / $2,951.21
| Professional | | $724.44 | $2,238.72 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,288.25 / $1,949.84
| Facility | | $776.25 | $1,288.25 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $1,548.82 / $1,862.09
| Professional | | $1,380.38 | $1,548.82 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,548.82 / $7,079.46
| Facility | | $776.25 | $1,548.82 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,023.29 / $1,737.80
| Professional | | $691.83 | $1,023.29 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $64.57 / $85.11
| Professional | | $54.95 | $64.57 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,778.28 / $3,090.30
| Professional | | $1,096.48 | $1,778.28 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $2,344.23 / $4,265.80
| Professional | | $1,548.82 | $2,344.23 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $3,090.30 / $7,244.36
| Facility | | $851.14 | $3,090.30 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $1,445.44 / $7,585.78
| Professional | | $724.44 | $1,445.44 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,023.29 / $1,548.82
| Facility | | $794.33 | $1,023.29 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $758.58 / $1,288.25
| Professional | | $588.84 | $758.58 | $1,288.25 |