- 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
- $794.33 / $1,071.52 / $1,071.52
| Professional | | $794.33 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $3,019.95 / $3,019.95
| Facility | | $1,659.59 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,659.59 / $2,089.30
| Professional | | $1,202.26 | $1,659.59 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $912.01 / $6,606.93
| Facility | | $912.01 | $912.01 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $2,041.74 / $3,235.94
| Professional | | $758.58 | $2,041.74 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $1,202.26 / $1,949.84
| Facility | | $512.86 | $1,202.26 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,071.52 / $1,071.52
| Professional | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $1,621.81 / $8,511.38
| Facility | | $512.86 | $1,621.81 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $933.25 / $1,513.56
| Professional | | $776.25 | $933.25 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $100.00 / $1,258.93
| Professional | | $54.95 | $100.00 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,174.90 / $1,258.93
| Professional | | $794.33 | $1,174.90 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $371.54 / $416.87
| Professional | | $186.21 | $371.54 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $3,019.95 / $8,912.51
| Facility | | $912.01 | $3,019.95 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $912.01 / $912.01
| Professional | | $128.82 | $912.01 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $602.56 / $1,230.27
| Facility | | $74.13 | $602.56 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $891.25 / $1,659.59
| Professional | | $630.96 | $891.25 | $1,659.59 |