- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $1,659.59 / $12,302.69
| Professional | | $758.58 | $1,659.59 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $2,511.89 / $2,570.40
| Professional | | $2,290.87 | $2,511.89 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $1,819.70 / $2,951.21
| Facility | | $1,819.70 | $1,819.70 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $3,235.94 / $4,466.84
| Professional | | $1,819.70 | $3,235.94 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $2,884.03 / $12,589.25
| Facility | | $1,659.59 | $2,884.03 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,548.82 / $2,630.27
| Professional | | $870.96 | $1,548.82 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,884.03 / $2,884.03 / $7,079.46
| Professional | | $2,884.03 | $2,884.03 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,630.78 / $6,456.54 / $7,079.46
| Professional | | $3,630.78 | $6,456.54 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,737.80 / $2,691.53
| Facility | | $1,348.96 | $1,737.80 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,288.25 / $2,041.74
| Professional | | $933.25 | $1,288.25 | $2,041.74 |