- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $1,288.25 / $8,912.51
| Professional | | $660.69 | $1,288.25 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,995.26 / $1,995.26
| Professional | | $1,778.28 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $1,380.38 / $2,290.87
| Facility | | $1,380.38 | $1,380.38 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $2,454.71 / $3,890.45
| Professional | | $1,380.38 | $2,454.71 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $2,290.87 / $10,232.93
| Facility | | $1,318.26 | $2,290.87 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $1,258.93 / $2,089.30
| Professional | | $676.08 | $1,258.93 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,238.72 / $2,238.72 / $5,495.41
| Professional | | $2,238.72 | $2,238.72 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,818.38 / $5,128.61 / $5,495.41
| Professional | | $2,818.38 | $5,128.61 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,548.82 / $2,344.23
| Facility | | $912.01 | $1,548.82 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $1,023.29 / $1,584.89
| Professional | | $741.31 | $1,023.29 | $1,584.89 |