- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $1,096.48 / $1,348.96
| Professional | | $707.95 | $1,096.48 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $1,096.48 / $1,949.84
| Facility | | $109.65 | $1,096.48 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $891.25 / $1,513.56
| Professional | | $144.54 | $891.25 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $446.68 / $467.74
| Facility | | $446.68 | $446.68 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $380.19 / $446.68
| Professional | | $97.72 | $380.19 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $645.65 / $1,174.90
| Facility | | $144.54 | $645.65 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $1,096.48 / $1,348.96
| Professional | | $707.95 | $1,096.48 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $85.11 / $870.96
| Professional | | $64.57 | $85.11 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $851.14 / $891.25
| Professional | | $851.14 | $851.14 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,230.27 / $1,230.27
| Professional | | $912.01 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $416.87 / $954.99
| Facility | | $47.86 | $416.87 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $562.34 / $891.25
| Professional | | $478.63 | $562.34 | $891.25 |