- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $1,737.80 / $11,748.98
| Professional | | $660.69 | $1,737.80 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $2,630.27 / $2,691.53
| Professional | | $2,398.83 | $2,630.27 | $2,691.53 |
- 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 / $3,019.95 / $4,677.35
| Professional | | $1,621.81 | $3,019.95 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $3,019.95 / $10,715.19
| Facility | | $1,584.89 | $3,019.95 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,348.96 / $2,754.23
| Professional | | $912.01 | $1,348.96 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,019.95 / $3,019.95 / $7,413.10
| Professional | | $3,019.95 | $3,019.95 | $7,413.10 |
- 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
- $3,801.89 / $6,760.83 / $7,413.10
| Professional | | $3,801.89 | $6,760.83 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,548.82 / $2,344.23
| Facility | | $1,348.96 | $1,548.82 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,348.96 / $2,137.96
| Professional | | $933.25 | $1,348.96 | $2,137.96 |