- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,995.26 / $16,218.10
| Professional | | $912.01 | $1,995.26 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,754.23 / $3,019.95 / $3,090.30
| Professional | | $2,754.23 | $3,019.95 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,778.28 / $3,548.13
| Facility | | $1,778.28 | $1,778.28 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $3,981.07 / $5,495.41
| Professional | | $1,778.28 | $3,981.07 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,995.26 / $3,467.37 / $14,791.08
| Facility | | $1,995.26 | $3,467.37 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,862.09 / $3,162.28
| Professional | | $1,047.13 | $1,862.09 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,467.37 / $3,467.37 / $8,511.38
| Professional | | $3,467.37 | $3,467.37 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,548.13 / $3,548.13 / $3,548.13
| Facility | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,365.16 / $7,762.47 / $8,511.38
| Professional | | $4,365.16 | $7,762.47 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $2,137.96 / $3,235.94
| Facility | | $1,288.25 | $2,137.96 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,548.82 / $2,454.71
| Professional | | $1,122.02 | $1,548.82 | $2,454.71 |