- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,258.93 / $1,659.59
| Facility | | $1,258.93 | $1,258.93 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,258.93 / $1,995.26
| Professional | | $831.76 | $1,258.93 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,548.82 / $2,238.72
| Facility | | $1,548.82 | $1,548.82 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $2,754.23 / $3,467.37
| Professional | | $1,548.82 | $2,754.23 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $2,187.76 / $2,398.83
| Professional | | $1,905.46 | $2,187.76 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $2,630.27 / $10,964.78
| Facility | | $1,380.38 | $2,630.27 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,288.25 / $3,388.44
| Professional | | $954.99 | $1,288.25 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $2,290.87 / $3,090.30
| Professional | | $2,187.76 | $2,290.87 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $3,388.44 / $3,388.44
| Professional | | $2,290.87 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $2,041.74 / $5,370.32
| Facility | | $776.25 | $2,041.74 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,000.00 / $1,995.26
| Professional | | $954.99 | $1,000.00 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,995.26 / $1,995.26
| Professional | | $1,548.82 | $1,995.26 | $1,995.26 |