- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $2,137.96 / $2,137.96
| Facility | | $1,584.89 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,258.93 / $2,137.96
| Professional | | $891.25 | $1,258.93 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,621.81 / $3,090.30
| Facility | | $1,621.81 | $1,621.81 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $2,951.21 / $3,630.78
| Professional | | $1,621.81 | $2,951.21 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $2,818.38 / $3,388.44
| Professional | | $2,187.76 | $2,818.38 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,862.09 / $3,311.31 / $10,715.19
| Facility | | $1,862.09 | $3,311.31 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,584.89 / $4,570.88
| Professional | | $1,258.93 | $1,584.89 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,019.95 / $3,090.30 / $3,548.13
| Professional | | $3,019.95 | $3,090.30 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,090.30 / $3,090.30 / $3,090.30
| Facility | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,344.23 / $4,570.88 / $4,570.88
| Professional | | $2,344.23 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $2,818.38 / $5,495.41
| Facility | | $1,023.29 | $2,818.38 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,348.96 / $2,511.89
| Professional | | $1,148.15 | $1,348.96 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $2,691.53 / $2,691.53
| Professional | | $2,137.96 | $2,691.53 | $2,691.53 |