- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $407.38 / $3,890.45
| Facility | | $407.38 | $407.38 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $407.38 / $3,388.44
| Professional | | $295.12 | $407.38 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $389.05 / $1,778.28
| Facility | | $309.03 | $389.05 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $407.38 / $1,096.48
| Professional | | $407.38 | $407.38 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $1,318.26 / $2,089.30
| Facility | | $537.03 | $1,318.26 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $1,659.59 / $3,388.44
| Professional | | $851.14 | $1,659.59 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $416.87 / $446.68
| Facility | | $416.87 | $416.87 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $416.87
| Professional | | $309.03 | $309.03 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $512.86 / $1,096.48
| Professional | | $416.87 | $512.86 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $812.83 / $1,412.54
| Professional | | $549.54 | $812.83 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,365.16 / $5,128.61 / $5,128.61
| Professional | | $4,365.16 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $851.14 / $851.14
| Professional | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $54.95 / $70.79
| Professional | | $54.95 | $54.95 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $758.58 / $1,096.48
| Facility | | $251.19 | $758.58 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $660.69
| Professional | | $309.03 | $309.03 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $1,698.24 / $1,698.24
| Professional | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $537.03 / $812.83
| Professional | | $416.87 | $537.03 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $446.68 / $912.01
| Facility | | $54.95 | $446.68 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $407.38 / $933.25
| Professional | | $316.23 | $407.38 | $933.25 |