- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $2,398.83 / $18,620.87
| Professional | | $1,047.13 | $2,398.83 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,311.31 / $3,630.78 / $3,715.35
| Professional | | $3,311.31 | $3,630.78 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,570.40 / $2,570.40 / $4,265.80
| Facility | | $2,570.40 | $2,570.40 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,570.40 / $4,466.84 / $6,456.54
| Professional | | $2,570.40 | $4,466.84 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $4,168.69 / $16,982.44
| Facility | | $2,398.83 | $4,168.69 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $2,137.96 / $3,801.89
| Professional | | $1,258.93 | $2,137.96 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,168.69 / $4,168.69 / $10,232.93
| Professional | | $4,168.69 | $4,168.69 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,265.80 / $4,265.80 / $4,265.80
| Facility | | $4,265.80 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,248.07 / $9,549.93 / $10,232.93
| Professional | | $5,248.07 | $9,549.93 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $2,398.83 / $3,715.35
| Facility | | $1,513.56 | $2,398.83 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $1,905.46 / $2,951.21
| Professional | | $1,380.38 | $1,905.46 | $2,951.21 |