- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,230.27 / $1,230.27
| Facility | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $1,230.27 / $1,513.56
| Professional | | $676.08 | $1,230.27 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $223.87 / $2,238.72
| Facility | | $123.03 | $223.87 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $1,023.29 / $1,479.11
| Professional | | $138.04 | $1,023.29 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $831.76 / $1,023.29
| Facility | | $831.76 | $831.76 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $707.95 / $851.14
| Professional | | $107.15 | $707.95 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $676.08 / $1,380.38
| Facility | | $131.83 | $676.08 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $1,230.27 / $1,513.56
| Professional | | $676.08 | $1,230.27 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $724.44 / $977.24
| Professional | | $74.13 | $724.44 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $954.99 / $1,023.29
| Professional | | $954.99 | $954.99 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,380.38 / $1,412.54
| Professional | | $1,096.48 | $1,380.38 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $549.54 / $1,047.13
| Facility | | $57.54 | $549.54 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $691.83 / $1,047.13
| Professional | | $630.96 | $691.83 | $1,047.13 |