- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,659.59 / $3,467.37
| Professional | | $1,348.96 | $1,659.59 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $524.81 / $7,762.47
| Facility | | $371.54 | $524.81 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $1,819.70 / $4,265.80
| Professional | | $407.38 | $1,819.70 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $302.00 / $316.23
| Facility | | $302.00 | $302.00 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $257.04 / $302.00
| Professional | | $190.55 | $257.04 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $1,905.46 / $3,467.37
| Facility | | $354.81 | $1,905.46 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,659.59 / $3,467.37
| Professional | | $1,348.96 | $1,659.59 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $2,089.30 / $2,818.38
| Professional | | $213.80 | $2,089.30 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $1,737.80 / $2,630.27
| Professional | | $1,737.80 | $1,737.80 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,454.71 / $2,511.89 / $4,073.80
| Professional | | $2,454.71 | $2,511.89 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $245.47 / $2,754.23
| Facility | | $138.04 | $245.47 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $208.93 / $2,454.71
| Professional | | $128.82 | $208.93 | $2,454.71 |