- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $2,187.76 / $16,218.10
| Professional | | $912.01 | $2,187.76 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,019.95 / $3,311.31 / $3,311.31
| Professional | | $3,019.95 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,778.28 / $3,801.89
| Facility | | $1,778.28 | $1,778.28 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $4,168.69 / $5,754.40
| Professional | | $1,778.28 | $4,168.69 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $3,715.35 / $15,135.61
| Facility | | $2,187.76 | $3,715.35 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,905.46 / $3,388.44
| Professional | | $1,122.02 | $1,905.46 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,715.35 / $3,715.35 / $9,120.11
| Professional | | $3,715.35 | $3,715.35 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,801.89 / $3,801.89 / $3,801.89
| Facility | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,677.35 / $8,511.38 / $9,120.11
| Professional | | $4,677.35 | $8,511.38 | $9,120.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $2,137.96 / $3,311.31
| Facility | | $1,621.81 | $2,137.96 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,698.24 / $2,691.53
| Professional | | $1,230.27 | $1,698.24 | $2,691.53 |