- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $1,513.56 / $1,513.56
| Facility | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,513.56 / $10,232.93
| Professional | | $691.83 | $1,513.56 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $2,344.23 / $2,344.23
| Professional | | $2,089.30 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,348.96 / $2,691.53
| Facility | | $1,348.96 | $1,348.96 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $2,818.38 / $4,168.69
| Professional | | $1,348.96 | $2,818.38 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $2,630.27 / $11,220.18
| Facility | | $1,513.56 | $2,630.27 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,412.54 / $2,398.83
| Professional | | $794.33 | $1,412.54 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,630.27 / $2,630.27 / $6,456.54
| Professional | | $2,630.27 | $2,630.27 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,311.31 / $6,025.60 / $6,456.54
| Professional | | $3,311.31 | $6,025.60 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $1,659.59 / $2,511.89
| Facility | | $1,412.54 | $1,659.59 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,202.26 / $1,862.09
| Professional | | $870.96 | $1,202.26 | $1,862.09 |