- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $1,380.38 / $10,471.29
| Professional | | $588.84 | $1,380.38 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $2,137.96 / $2,137.96
| Professional | | $1,905.46 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,584.89 / $2,454.71
| Facility | | $1,584.89 | $1,584.89 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $2,818.38 / $3,715.35
| Professional | | $1,584.89 | $2,818.38 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $2,398.83 / $9,772.37
| Facility | | $1,380.38 | $2,398.83 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $1,202.26 / $2,187.76
| Professional | | $724.44 | $1,202.26 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $2,398.83 / $5,888.44
| Professional | | $2,398.83 | $2,398.83 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,454.71 / $2,454.71 / $2,454.71
| Facility | | $2,454.71 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,019.95 / $5,495.41 / $5,888.44
| Professional | | $3,019.95 | $5,495.41 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,380.38 / $2,089.30
| Facility | | $1,202.26 | $1,380.38 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,096.48 / $1,698.24
| Professional | | $794.33 | $1,096.48 | $1,698.24 |