- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,584.89 / $1,584.89
| Facility | | $1,584.89 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $1,584.89 / $13,182.57
| Professional | | $741.31 | $1,584.89 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $2,398.83 / $2,454.71
| Professional | | $2,187.76 | $2,398.83 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $1,659.59 / $2,818.38
| Facility | | $1,659.59 | $1,659.59 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $2,754.23 / $4,365.16
| Professional | | $1,659.59 | $2,754.23 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $2,754.23 / $12,022.64
| Facility | | $1,584.89 | $2,754.23 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,513.56 / $2,511.89
| Professional | | $831.76 | $1,513.56 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,754.23 / $2,754.23 / $6,760.83
| Professional | | $2,754.23 | $2,754.23 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,818.38 / $2,818.38 / $2,818.38
| Facility | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,467.37 / $6,165.95 / $6,760.83
| Professional | | $3,467.37 | $6,165.95 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,698.24 / $2,630.27
| Facility | | $1,202.26 | $1,698.24 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,230.27 / $1,949.84
| Professional | | $891.25 | $1,230.27 | $1,949.84 |