- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $2,089.30 / $2,089.30
| Facility | | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $2,089.30 / $12,882.50
| Professional | | $794.33 | $2,089.30 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,884.03 / $3,235.94 / $3,235.94
| Professional | | $2,884.03 | $3,235.94 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,548.82 / $3,715.35
| Facility | | $1,548.82 | $1,548.82 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $3,630.78 / $5,623.41
| Professional | | $1,548.82 | $3,630.78 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $3,630.78 / $13,489.63
| Facility | | $2,089.30 | $3,630.78 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,659.59 / $3,311.31
| Professional | | $1,096.48 | $1,659.59 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,630.78 / $3,630.78 / $8,912.51
| Professional | | $3,630.78 | $3,630.78 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,570.88 / $8,317.64 / $8,912.51
| Professional | | $4,570.88 | $8,317.64 | $8,912.51 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,479.11 / $1,862.09 / $2,884.03
| Facility | | $1,479.11 | $1,862.09 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,659.59 / $2,570.40
| Professional | | $1,122.02 | $1,659.59 | $2,570.40 |