- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $4,073.80 / $4,073.80
| Facility | | $1,071.52 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,230.27 / $1,819.70
| Professional | | $891.25 | $1,230.27 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5,011.87 / $8,511.38 / $77,624.71
| Facility | | $5,011.87 | $8,511.38 | $77,624.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,949.84 / $2,398.83
| Professional | | $1,318.26 | $1,949.84 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,621.81 / $2,137.96
| Facility | | $1,621.81 | $1,621.81 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,621.81
| Professional | | $1,174.90 | $1,174.90 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $2,818.38 / $4,073.80
| Professional | | $1,949.84 | $2,818.38 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,584.89 / $2,398.83
| Professional | | $1,445.44 | $1,584.89 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,230.27 / $1,819.70
| Professional | | $891.25 | $1,230.27 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $2,818.38 / $4,073.80
| Professional | | $1,548.82 | $2,818.38 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,148.15 / $2,238.72
| Facility | | $1,148.15 | $1,148.15 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,148.15 / $2,238.72
| Professional | | $1,148.15 | $1,148.15 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $2,818.38 / $3,235.94
| Facility | | $933.25 | $2,818.38 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,288.25 / $2,137.96
| Professional | | $1,000.00 | $1,288.25 | $2,137.96 |