- 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
- $223.87 / $223.87 / $2,238.72
| Facility | | $223.87 | $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
- $794.33 / $794.33 / $831.76
| Facility | | $794.33 | $794.33 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $676.08 / $812.83
| Professional | | $107.15 | $676.08 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $389.05 / $1,047.13
| Facility | | $131.83 | $389.05 | $1,047.13 |
- 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
- $97.72 / $977.24 / $977.24
| Professional | | $97.72 | $977.24 | $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
- $954.99 / $1,380.38 / $1,412.54
| Professional | | $954.99 | $1,380.38 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $426.58 / $1,047.13
| Facility | | $52.48 | $426.58 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $562.34 / $954.99
| Professional | | $489.78 | $562.34 | $954.99 |