- 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
- $1,174.90 / $1,659.59 / $2,041.74
| Professional | | $1,174.90 | $1,659.59 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,995.26 / $1,995.26 / $1,995.26
| Professional | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $1,905.46 / $1,905.46
| Professional | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,202.26 / $1,949.84
| Facility | | $1,202.26 | $1,202.26 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $1,023.29 / $1,202.26
| Professional | | $199.53 | $1,023.29 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,995.26 / $2,290.87 / $3,162.28
| Professional | | $1,995.26 | $2,290.87 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,348.96 / $1,737.80
| Professional | | $1,348.96 | $1,348.96 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $1,096.48 / $1,659.59
| Facility | | $275.42 | $1,096.48 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $323.59 / $2,238.72
| Facility | | $177.83 | $323.59 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $323.59 / $2,238.72
| Professional | | $177.83 | $323.59 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $741.31 / $1,348.96
| Facility | | $91.20 | $741.31 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,202.26 / $1,949.84
| Professional | | $1,047.13 | $1,202.26 | $1,949.84 |