- 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 / $1,513.56
| Professional | | $691.83 | $1,071.52 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $1,230.27 / $2,238.72
| Facility | | $123.03 | $1,230.27 | $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 / $891.25
| Facility | | $831.76 | $831.76 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $707.95 / $831.76
| Professional | | $97.72 | $707.95 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $602.56 / $1,071.52
| Facility | | $131.83 | $602.56 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,071.52 / $1,513.56
| Professional | | $691.83 | $1,071.52 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $97.72 / $977.24
| Professional | | $72.44 | $97.72 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $977.24 / $1,023.29
| Professional | | $977.24 | $977.24 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,412.54 / $1,412.54
| Professional | | $1,023.29 | $1,412.54 | $1,412.54 |
- 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 |