- 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 / $1,949.84
| Professional | | $1,174.90 | $1,659.59 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $2,089.30 / $2,089.30
| Professional | | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $1,949.84 / $1,949.84
| Professional | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $1,412.54 / $2,041.74
| Facility | | $213.80 | $1,412.54 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $1,202.26 / $1,412.54
| Professional | | $213.80 | $1,202.26 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $2,398.83 / $2,951.21
| Professional | | $2,089.30 | $2,398.83 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $1,412.54 / $2,290.87
| Professional | | $1,412.54 | $1,412.54 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,659.59 / $2,754.23
| Facility | | $776.25 | $1,659.59 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $295.12 / $2,570.40
| Facility | | $177.83 | $295.12 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $295.12 / $2,570.40
| Professional | | $177.83 | $295.12 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $1,023.29 / $1,819.70
| Facility | | $120.23 | $1,023.29 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,412.54 / $2,344.23
| Professional | | $1,288.25 | $1,412.54 | $2,344.23 |