- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $1,148.15 / $7,585.78
| Professional | | $457.09 | $1,148.15 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,737.80 / $1,737.80
| Professional | | $1,584.89 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $891.25 / $1,995.26
| Facility | | $891.25 | $891.25 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $2,041.74 / $3,019.95
| Professional | | $891.25 | $2,041.74 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,949.84 / $7,585.78
| Facility | | $1,148.15 | $1,949.84 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $954.99 / $1,778.28
| Professional | | $588.84 | $954.99 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $1,949.84 / $4,786.30
| Professional | | $1,949.84 | $1,949.84 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,454.71 / $4,466.84 / $4,786.30
| Professional | | $2,454.71 | $4,466.84 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,071.52 / $1,659.59
| Facility | | $870.96 | $1,071.52 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $891.25 / $1,412.54
| Professional | | $645.65 | $891.25 | $1,412.54 |