- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $4,677.35 / $4,677.35
| Facility | | $1,202.26 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,548.82 / $2,238.72
| Professional | | $1,202.26 | $1,548.82 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5,011.87 / $8,511.38 / $77,624.71
| Facility | | $5,011.87 | $8,511.38 | $77,624.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $2,398.83 / $3,019.95
| Professional | | $1,659.59 | $2,398.83 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $1,819.70 / $2,884.03
| Facility | | $1,819.70 | $1,819.70 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,318.26 / $1,819.70
| Professional | | $1,318.26 | $1,318.26 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,754.23 / $3,981.07 / $5,754.40
| Professional | | $2,754.23 | $3,981.07 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $2,089.30 / $3,019.95
| Professional | | $1,819.70 | $2,089.30 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,584.89 / $2,238.72
| Professional | | $1,202.26 | $1,584.89 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $3,981.07 / $5,754.40
| Professional | | $0.60 | $3,981.07 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $2,089.30 / $2,818.38
| Facility | | $2,089.30 | $2,089.30 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $2,089.30 / $2,884.03
| Professional | | $2,089.30 | $2,089.30 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $3,981.07 / $4,570.88
| Facility | | $1,445.44 | $3,981.07 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,479.11 / $3,019.95
| Professional | | $1,148.15 | $1,479.11 | $3,019.95 |