- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $2,630.27 / $5,495.41
| Facility | | $1,174.90 | $2,630.27 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $831.76 / $2,041.74
| Professional | | $691.83 | $831.76 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $851.14 / $2,089.30
| Professional | | $691.83 | $851.14 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,148.15 / $1,148.15
| Professional | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $316.23 / $3,019.95
| Facility | | $263.03 | $316.23 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $1,380.38 / $3,467.37
| Professional | | $676.08 | $1,380.38 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,380.38 / $3,715.35
| Facility | | $891.25 | $1,380.38 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,479.11 / $2,238.72
| Professional | | $1,071.52 | $1,479.11 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $263.03 / $263.03
| Facility | | $263.03 | $263.03 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $912.01 / $1,548.82
| Professional | | $316.23 | $912.01 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,819.70 / $53,703.18
| Facility | | $912.01 | $1,819.70 | $53,703.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,174.90 / $1,819.70
| Professional | | $1,000.00 | $1,174.90 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $288.40 / $1,148.15
| Facility | | $190.55 | $288.40 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $1,174.90 / $3,019.95
| Professional | | $741.31 | $1,174.90 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $524.81 / $1,023.29
| Facility | | $263.03 | $524.81 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $1,023.29 / $2,089.30
| Professional | | $562.34 | $1,023.29 | $2,089.30 |