- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,570.40 / $2,570.40 / $2,570.40
| Facility | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,737.80 / $2,570.40
| Professional | | $912.01 | $1,737.80 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,445.44 / $1,445.44
| Facility | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,230.27 / $1,230.27
| Professional | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $6,025.60 / $7,079.46 / $7,943.28
| Professional | | $6,025.60 | $7,079.46 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $323.59 / $2,630.27
| Facility | | $251.19 | $323.59 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $2,454.71 / $2,570.40
| Professional | | $2,398.83 | $2,454.71 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $2,818.38 / $5,495.41
| Facility | | $323.59 | $2,818.38 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $4,168.69 / $5,495.41
| Professional | | $331.13 | $4,168.69 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $1,995.26 / $3,981.07
| Facility | | $338.84 | $1,995.26 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $1,230.27 / $1,445.44
| Professional | | $79.43 | $1,230.27 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,454.71 / $3,388.44 / $3,715.35
| Professional | | $2,454.71 | $3,388.44 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $1,174.90 / $2,187.76
| Facility | | $128.82 | $1,174.90 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,380.38 / $2,344.23
| Professional | | $1,174.90 | $1,380.38 | $2,344.23 |