- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $1,122.02
| Facility | | $1,122.02 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $1,122.02 / $1,584.89
| Professional | | $724.44 | $1,122.02 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $1,288.25 / $2,344.23
| Facility | | $128.82 | $1,288.25 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $1,071.52 / $1,548.82
| Professional | | $147.91 | $1,071.52 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $208.93
| Facility | | $199.53 | $199.53 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $169.82 / $199.53
| Professional | | $97.72 | $169.82 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $660.69 / $1,122.02
| Facility | | $147.91 | $660.69 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $1,122.02 / $1,584.89
| Professional | | $724.44 | $1,122.02 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $102.33 / $1,047.13
| Professional | | $75.86 | $102.33 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,023.29 / $1,071.52
| Professional | | $1,023.29 | $1,023.29 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,479.11 / $1,479.11
| Professional | | $1,096.48 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $426.58 / $954.99
| Facility | | $47.86 | $426.58 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $562.34 / $891.25
| Professional | | $489.78 | $562.34 | $891.25 |