- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,737.80 / $12,589.25
| Professional | | $691.83 | $1,737.80 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $2,630.27 / $2,630.27
| Professional | | $2,398.83 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,584.89 / $3,019.95
| Facility | | $1,584.89 | $1,584.89 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $2,951.21 / $4,570.88
| Professional | | $1,584.89 | $2,951.21 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $2,951.21 / $11,481.54
| Facility | | $1,737.80 | $2,951.21 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,445.44 / $2,691.53
| Professional | | $891.25 | $1,445.44 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,951.21 / $2,951.21 / $7,244.36
| Professional | | $2,951.21 | $2,951.21 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,715.35 / $6,760.83 / $7,244.36
| Professional | | $3,715.35 | $6,760.83 | $7,244.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,621.81 / $2,511.89
| Facility | | $1,258.93 | $1,621.81 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $1,348.96 / $2,137.96
| Professional | | $977.24 | $1,348.96 | $2,137.96 |