- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,258.93 / $1,258.93
| Facility | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,258.93 / $2,089.30
| Professional | | $912.01 | $1,258.93 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,174.90
| Professional | | $1,174.90 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $4,570.88 / $5,623.41
| Professional | | $1,584.89 | $4,570.88 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,584.89 / $2,290.87
| Facility | | $1,258.93 | $1,584.89 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,698.24 / $2,344.23
| Professional | | $1,548.82 | $1,698.24 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $2,041.74 / $2,290.87
| Facility | | $1,659.59 | $2,041.74 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $2,187.76 / $2,398.83
| Professional | | $2,089.30 | $2,187.76 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,819.70 / $2,570.40
| Facility | | $1,174.90 | $1,819.70 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $1,819.70 / $2,187.76
| Professional | | $79.43 | $1,819.70 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $3,311.31 / $8,128.31
| Facility | | $1,737.80 | $3,311.31 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $2,344.23 / $2,344.23
| Professional | | $2,089.30 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,584.89 / $3,388.44
| Facility | | $794.33 | $1,584.89 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,047.13 / $1,995.26
| Professional | | $831.76 | $1,047.13 | $1,995.26 |