- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,230.27 / $1,230.27
| Facility | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $1,230.27 / $9,120.11
| Professional | | $562.34 | $1,230.27 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $1,862.09 / $1,905.46
| Professional | | $1,698.24 | $1,862.09 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,096.48 / $2,187.76
| Facility | | $1,096.48 | $1,096.48 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $2,344.23 / $3,388.44
| Professional | | $1,096.48 | $2,344.23 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $2,137.96 / $9,332.54
| Facility | | $1,230.27 | $2,137.96 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $977.24 / $1,949.84
| Professional | | $645.65 | $977.24 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $2,137.96 / $5,248.07
| Professional | | $2,137.96 | $2,137.96 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,691.53 / $4,897.79 / $5,248.07
| Professional | | $2,691.53 | $4,897.79 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $1,047.13 / $2,041.74
| Facility | | $676.08 | $1,047.13 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $977.24 / $1,513.56
| Professional | | $707.95 | $977.24 | $1,513.56 |