- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $1,096.48 / $7,413.10
| Professional | | $478.63 | $1,096.48 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $1,659.59 / $1,698.24
| Professional | | $1,513.56 | $1,659.59 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,230.27 / $1,949.84
| Facility | | $1,230.27 | $1,230.27 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $2,089.30 / $2,951.21
| Professional | | $1,230.27 | $2,089.30 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,905.46 / $7,762.47
| Facility | | $1,023.29 | $1,905.46 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $977.24 / $1,737.80
| Professional | | $575.44 | $977.24 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $1,905.46 / $4,677.35
| Professional | | $1,905.46 | $1,905.46 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $1,949.84 / $1,949.84
| Facility | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $4,265.80 / $4,677.35
| Professional | | $2,398.83 | $4,265.80 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $1,122.02 / $1,698.24
| Facility | | $851.14 | $1,122.02 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $870.96 / $1,348.96
| Professional | | $630.96 | $870.96 | $1,348.96 |