- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $1,318.26 / $10,964.78
| Professional | | $676.08 | $1,318.26 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,584.89 / $1,584.89
| Professional | | $1,584.89 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $2,041.74 / $2,041.74
| Professional | | $1,819.70 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,318.26 / $2,344.23
| Facility | | $1,318.26 | $1,318.26 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $2,570.40 / $3,981.07
| Professional | | $1,318.26 | $2,570.40 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $2,344.23 / $11,220.18
| Facility | | $1,318.26 | $2,344.23 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,047.13 / $2,187.76
| Professional | | $691.83 | $1,047.13 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $2,290.87 / $5,623.41
| Professional | | $2,290.87 | $2,290.87 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,344.23 / $2,344.23 / $2,344.23
| Facility | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,884.03 / $5,248.07 / $5,623.41
| Professional | | $2,884.03 | $5,248.07 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,230.27 / $2,398.83
| Facility | | $794.33 | $1,230.27 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $1,047.13 / $1,621.81
| Professional | | $758.58 | $1,047.13 | $1,621.81 |