- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,047.13 / $1,584.89
| Professional | | $870.96 | $1,047.13 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $2,041.74 / $2,137.96
| Facility | | $2,041.74 | $2,041.74 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $2,344.23
| Professional | | $1,122.02 | $1,122.02 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $1,380.38 / $1,380.38
| Professional | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,318.26 / $1,318.26
| Facility | | $870.96 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $954.99 / $1,318.26
| Professional | | $954.99 | $954.99 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $2,041.74 / $2,818.38
| Professional | | $1,513.56 | $2,041.74 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,318.26 / $1,995.26
| Professional | | $1,023.29 | $1,318.26 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,380.38 / $2,344.23
| Facility | | $870.96 | $1,380.38 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,318.26 / $2,951.21
| Professional | | $1,096.48 | $1,318.26 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,659.59 / $4,168.69
| Facility | | $1,148.15 | $1,659.59 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,659.59 / $4,168.69
| Professional | | $1,148.15 | $1,659.59 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,380.38 / $2,454.71
| Facility | | $691.83 | $1,380.38 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,000.00 / $1,584.89
| Professional | | $933.25 | $1,000.00 | $1,584.89 |