- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $6,025.60 / $13,489.63
| Facility | | $1,258.93 | $6,025.60 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,047.13 / $1,584.89
| Professional | | $794.33 | $1,047.13 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,995.26 / $2,691.53
| Facility | | $1,348.96 | $1,995.26 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,348.96 / $1,737.80
| Professional | | $1,148.15 | $1,348.96 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $2,951.21 / $3,467.37
| Facility | | $1,380.38 | $2,951.21 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,348.96 / $6,165.95
| Facility | | $1,348.96 | $1,348.96 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,348.96 / $2,290.87
| Professional | | $1,202.26 | $1,348.96 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $75.86
| Professional | | $75.86 | $75.86 | $75.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,348.96 / $1,348.96
| Facility | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $2,137.96 / $4,168.69
| Facility | | $1,348.96 | $2,137.96 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,202.26 / $1,621.81
| Professional | | $1,202.26 | $1,202.26 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,995.26 / $3,090.30
| Facility | | $1,548.82 | $1,995.26 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,348.96 / $1,737.80
| Professional | | $1,148.15 | $1,348.96 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,258.93 / $1,348.96
| Facility | | $1,258.93 | $1,258.93 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $562.34 / $1,513.56
| Professional | | $562.34 | $562.34 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $1,348.96 / $2,398.83
| Professional | | $602.56 | $1,348.96 | $2,398.83 |