- 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
- $891.25 / $1,071.52 / $1,380.38
| Professional | | $891.25 | $1,071.52 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $1,412.54 / $1,412.54
| Professional | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,258.93 / $1,258.93
| Professional | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $501.19 / $1,258.93
| Facility | | $501.19 | $501.19 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $426.58 / $501.19
| Professional | | $154.88 | $426.58 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,862.09 / $2,187.76
| Professional | | $1,621.81 | $1,862.09 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $1,380.38
| Professional | | $1,122.02 | $1,122.02 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $1,071.52 / $2,089.30
| Facility | | $602.56 | $1,071.52 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $758.58 / $1,905.46
| Facility | | $114.82 | $758.58 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $281.84 / $1,862.09
| Professional | | $114.82 | $281.84 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $891.25 / $1,479.11
| Facility | | $112.20 | $891.25 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,122.02 / $1,778.28
| Professional | | $891.25 | $1,122.02 | $1,778.28 |