- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,202.26 / $1,698.24
| Professional | | $776.25 | $1,202.26 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $1,380.38 / $2,511.89
| Facility | | $138.04 | $1,380.38 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $1,148.15 / $1,659.59
| Professional | | $158.49 | $1,148.15 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $707.95 / $741.31
| Facility | | $707.95 | $707.95 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $602.56 / $707.95
| Professional | | $109.65 | $602.56 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $724.44 / $1,202.26
| Facility | | $158.49 | $724.44 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,202.26 / $1,698.24
| Professional | | $776.25 | $1,202.26 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $109.65 / $1,122.02
| Professional | | $81.28 | $109.65 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,096.48 / $1,148.15
| Professional | | $1,096.48 | $1,096.48 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,584.89 / $1,584.89
| Professional | | $1,174.90 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $457.09 / $1,023.29
| Facility | | $52.48 | $457.09 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $602.56 / $954.99
| Professional | | $524.81 | $602.56 | $954.99 |