- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $2,089.30 / $2,089.30
| Facility | | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $2,089.30 / $2,511.89
| Professional | | $1,348.96 | $2,089.30 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $2,041.74 / $3,630.78
| Facility | | $204.17 | $2,041.74 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $1,698.24 / $2,884.03
| Professional | | $245.47 | $1,698.24 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,621.81 / $1,737.80
| Facility | | $1,621.81 | $1,621.81 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $1,380.38 / $1,621.81
| Professional | | $190.55 | $1,380.38 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $1,230.27 / $2,089.30
| Facility | | $269.15 | $1,230.27 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $2,089.30 / $2,511.89
| Professional | | $1,348.96 | $2,089.30 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $1,202.26 / $1,621.81
| Professional | | $123.03 | $1,202.26 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,621.81 / $1,698.24
| Professional | | $1,621.81 | $1,621.81 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $2,290.87 / $2,691.53
| Professional | | $1,698.24 | $2,290.87 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $891.25 / $1,778.28
| Facility | | $89.13 | $891.25 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,122.02 / $1,778.28
| Professional | | $1,047.13 | $1,122.02 | $1,778.28 |