- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,445.44 / $1,445.44
| Facility | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $1,445.44 / $1,698.24
| Professional | | $758.58 | $1,445.44 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $1,412.54 / $2,511.89
| Facility | | $141.25 | $1,412.54 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $1,122.02 / $1,737.80
| Professional | | $158.49 | $1,122.02 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $1,202.26
| Facility | | $645.65 | $645.65 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $549.54 / $660.69
| Professional | | $120.23 | $549.54 | $660.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $741.31 / $1,445.44
| Facility | | $154.88 | $741.31 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $1,445.44 / $1,698.24
| Professional | | $758.58 | $1,445.44 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $831.76 / $1,122.02
| Professional | | $85.11 | $831.76 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,071.52 / $1,122.02
| Professional | | $1,071.52 | $1,071.52 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,548.82 / $1,584.89
| Professional | | $1,288.25 | $1,548.82 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $645.65 / $1,202.26
| Facility | | $66.07 | $645.65 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $794.33 / $1,202.26
| Professional | | $741.31 | $794.33 | $1,202.26 |