- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $645.65 / $645.65
| Professional | | $436.52 | $645.65 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,698.24 / $1,698.24
| Facility | | $933.25 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $933.25 / $1,258.93
| Professional | | $776.25 | $933.25 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $741.31 / $3,715.35
| Facility | | $575.44 | $741.31 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $1,122.02 / $1,819.70
| Professional | | $575.44 | $1,122.02 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $831.76 / $1,318.26
| Facility | | $309.03 | $831.76 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $645.65
| Professional | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $1,148.15 / $4,168.69
| Facility | | $309.03 | $1,148.15 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $537.03 / $912.01
| Professional | | $436.52 | $537.03 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $64.57 / $741.31
| Professional | | $50.12 | $64.57 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $891.25 / $1,584.89
| Professional | | $562.34 | $891.25 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $194.98 / $263.03
| Professional | | $123.03 | $194.98 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $1,862.09 / $4,168.69
| Facility | | $575.44 | $1,862.09 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $575.44 / $707.95
| Professional | | $489.78 | $575.44 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $363.08 / $707.95
| Facility | | $44.67 | $363.08 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $524.81 / $933.25
| Professional | | $363.08 | $524.81 | $933.25 |