- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,174.90
| Facility | | $1,174.90 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $1,174.90 / $7,943.28
| Professional | | $446.68 | $1,174.90 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,778.28 / $1,778.28
| Professional | | $1,621.81 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,047.13 / $2,041.74
| Facility | | $1,047.13 | $1,047.13 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,995.26 / $3,090.30
| Professional | | $1,047.13 | $1,995.26 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,995.26 / $7,079.46
| Facility | | $1,047.13 | $1,995.26 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $912.01 / $1,819.70
| Professional | | $602.56 | $912.01 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,995.26 / $1,995.26 / $4,897.79
| Professional | | $1,995.26 | $1,995.26 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,511.89 / $4,570.88 / $4,897.79
| Professional | | $2,511.89 | $4,570.88 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,023.29 / $1,584.89
| Facility | | $912.01 | $1,023.29 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $912.01 / $1,445.44
| Professional | | $616.60 | $912.01 | $1,445.44 |