- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,584.89 / $1,584.89
| Facility | | $1,584.89 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,584.89 / $13,182.57
| Professional | | $776.25 | $1,584.89 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $2,398.83 / $2,398.83
| Professional | | $2,187.76 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,621.81 / $2,754.23
| Facility | | $1,621.81 | $1,621.81 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $2,951.21 / $4,677.35
| Professional | | $1,621.81 | $2,951.21 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $2,754.23 / $12,589.25
| Facility | | $1,584.89 | $2,754.23 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,230.27 / $2,570.40
| Professional | | $831.76 | $1,230.27 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,691.53 / $2,754.23 / $6,606.93
| Professional | | $2,691.53 | $2,754.23 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,467.37 / $6,165.95 / $6,606.93
| Professional | | $3,467.37 | $6,165.95 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,445.44 / $2,818.38
| Facility | | $933.25 | $1,445.44 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,230.27 / $1,862.09
| Professional | | $891.25 | $1,230.27 | $1,862.09 |