- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $1,995.26 / $5,754.40
| Facility | | $630.96 | $1,995.26 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,258.93 / $2,137.96
| Professional | | $870.96 | $1,258.93 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $2,089.30 / $3,715.35
| Facility | | $2,089.30 | $2,089.30 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $1,445.44 / $2,187.76
| Professional | | $758.58 | $1,445.44 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $2,754.23 / $3,388.44
| Professional | | $1,412.54 | $2,754.23 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,288.25 / $1,995.26
| Facility | | $1,258.93 | $1,288.25 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,548.82 / $1,905.46
| Professional | | $1,288.25 | $1,548.82 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,288.25 / $2,570.40
| Facility | | $1,288.25 | $1,288.25 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,288.25 / $1,548.82
| Professional | | $1,288.25 | $1,288.25 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,778.28 / $3,388.44
| Facility | | $1,148.15 | $1,778.28 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $1,412.54 / $1,862.09
| Professional | | $758.58 | $1,412.54 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $3,890.45 / $5,128.61
| Facility | | $1,949.84 | $3,890.45 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,096.48 / $1,548.82
| Professional | | $954.99 | $1,096.48 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $1,548.82 / $2,041.74
| Facility | | $575.44 | $1,548.82 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $537.03 / $1,548.82
| Professional | | $537.03 | $537.03 | $1,548.82 |