- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,071.52 / $1,288.25
| Professional | | $691.83 | $1,071.52 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $1,047.13 / $1,862.09
| Facility | | $104.71 | $1,047.13 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $870.96 / $1,479.11
| Professional | | $138.04 | $870.96 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $363.08 / $380.19
| Facility | | $363.08 | $363.08 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $309.03 / $363.08
| Professional | | $93.33 | $309.03 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $676.08 / $1,071.52
| Facility | | $138.04 | $676.08 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,071.52 / $1,288.25
| Professional | | $691.83 | $1,071.52 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $83.18 / $831.76
| Professional | | $61.66 | $83.18 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $831.76 / $870.96
| Professional | | $831.76 | $831.76 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,174.90 / $1,288.25
| Professional | | $870.96 | $1,174.90 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $407.38 / $912.01
| Facility | | $45.71 | $407.38 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $537.03 / $851.14
| Professional | | $457.09 | $537.03 | $851.14 |