- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $416.87 / $416.87
| Facility | | $416.87 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $416.87 / $562.34
| Professional | | $275.42 | $416.87 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $1,096.48 / $1,096.48
| Facility | | $602.56 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $602.56 / $812.83
| Professional | | $537.03 | $602.56 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $2,344.23
| Facility | | $380.19 | $380.19 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $707.95 / $1,174.90
| Professional | | $380.19 | $707.95 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $588.84 / $851.14
| Facility | | $354.81 | $588.84 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $489.78
| Professional | | $489.78 | $489.78 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $741.31 / $2,691.53
| Facility | | $354.81 | $741.31 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $407.38 / $676.08
| Professional | | $295.12 | $407.38 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $64.57 / $478.63
| Professional | | $50.12 | $64.57 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $575.44 / $1,023.29
| Professional | | $363.08 | $575.44 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $128.82 / $169.82
| Professional | | $79.43 | $128.82 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $1,202.26 / $2,691.53
| Facility | | $380.19 | $1,202.26 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $380.19 / $446.68
| Professional | | $316.23 | $380.19 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $33.11 / $251.19 / $457.09
| Facility | | $33.11 | $251.19 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $398.11 / $676.08
| Professional | | $245.47 | $398.11 | $676.08 |