- 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
- $1,584.89 / $1,819.70 / $4,073.80
| Professional | | $1,584.89 | $1,819.70 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $616.60 / $10,715.19
| Facility | | $407.38 | $616.60 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $1,819.70 / $5,370.32
| Professional | | $512.86 | $1,819.70 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,715.35 / $3,715.35 / $3,890.45
| Facility | | $3,715.35 | $3,715.35 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $3,162.28 / $3,715.35
| Professional | | $190.55 | $3,162.28 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $2,344.23 / $4,073.80
| Facility | | $251.19 | $2,344.23 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,659.59 / $4,073.80
| Professional | | $1,584.89 | $1,659.59 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $2,630.27 / $3,548.13
| Professional | | $269.15 | $2,630.27 | $3,548.13 |
- 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 / $5,128.61
| Professional | | $2,454.71 | $2,511.89 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $338.84 / $3,388.44
| Facility | | $138.04 | $338.84 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $616.60 / $3,388.44
| Professional | | $154.88 | $616.60 | $3,388.44 |