- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $1,584.89 / $1,737.80
| Professional | | $616.60 | $1,584.89 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Facility | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $141.25
| Professional | | $125.89 | $125.89 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $588.84
| Facility | | $169.82 | $169.82 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $131.83
| Professional | | $125.89 | $125.89 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $562.34 / $2,951.21
| Facility | | $346.74 | $562.34 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,951.21 / $3,311.31 / $4,786.30
| Professional | | $2,951.21 | $3,311.31 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $50.12 / $75.86
| Professional | | $50.12 | $50.12 | $75.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $1,584.89 / $1,819.70
| Facility | | $138.04 | $1,584.89 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $2,511.89 / $2,511.89
| Facility | | $1,949.84 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $1,949.84 / $1,949.84
| Professional | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Facility | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $125.89 / $141.25
| Professional | | $123.03 | $125.89 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $1,862.09
| Facility | | $102.33 | $102.33 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $1,862.09
| Professional | | $125.89 | $125.89 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $154.88 / $295.12
| Professional | | $134.90 | $154.88 | $295.12 |