- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,288.25 / $2,041.74
| Professional | | $891.25 | $1,288.25 | $2,041.74 |
- 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
- $2,398.83 / $2,398.83 / $2,818.38
| Professional | | $2,398.83 | $2,398.83 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $5,888.44 / $12,589.25
| Facility | | $1,621.81 | $5,888.44 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $3,630.78 / $4,897.79
| Professional | | $1,202.26 | $3,630.78 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $2,137.96 / $3,162.28
| Facility | | $1,258.93 | $2,137.96 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $2,511.89 / $3,090.30
| Professional | | $1,445.44 | $2,511.89 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $2,511.89 / $10,715.19
| Facility | | $1,288.25 | $2,511.89 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,513.56 / $2,884.03
| Professional | | $1,148.15 | $1,513.56 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $70.79 / $1,202.26
| Professional | | $54.95 | $70.79 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,073.80 / $4,073.80 / $4,073.80
| Facility | | $4,073.80 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $2,884.03 / $5,011.87
| Professional | | $1,819.70 | $2,884.03 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,570.40 / $3,890.45 / $6,456.54
| Professional | | $2,570.40 | $3,890.45 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $5,128.61 / $12,882.50
| Facility | | $1,621.81 | $5,128.61 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $2,398.83 / $14,791.08
| Professional | | $1,202.26 | $2,398.83 | $14,791.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,548.82 / $2,570.40
| Facility | | $1,348.96 | $1,548.82 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,258.93 / $2,089.30
| Professional | | $933.25 | $1,258.93 | $2,089.30 |