- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $1,949.84 / $1,949.84
| Facility | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,949.84 / $14,125.38
| Professional | | $794.33 | $1,949.84 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,691.53 / $2,951.21 / $3,019.95
| Professional | | $2,691.53 | $2,951.21 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,778.28 / $3,467.37
| Facility | | $1,778.28 | $1,778.28 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $3,715.35 / $5,248.07
| Professional | | $1,778.28 | $3,715.35 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $3,388.44 / $13,182.57
| Facility | | $1,949.84 | $3,388.44 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,621.81 / $3,090.30
| Professional | | $1,023.29 | $1,621.81 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,388.44 / $3,388.44 / $8,317.64
| Professional | | $3,388.44 | $3,388.44 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,467.37 / $3,467.37 / $3,467.37
| Facility | | $3,467.37 | $3,467.37 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,265.80 / $7,585.78 / $8,317.64
| Professional | | $4,265.80 | $7,585.78 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,862.09 / $2,818.38
| Facility | | $1,445.44 | $1,862.09 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,513.56 / $2,398.83
| Professional | | $1,096.48 | $1,513.56 | $2,398.83 |