- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $1,148.15 / $8,511.38
| Professional | | $575.44 | $1,148.15 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,737.80 / $1,778.28
| Professional | | $1,584.89 | $1,737.80 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,318.26 / $2,041.74
| Facility | | $1,318.26 | $1,318.26 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $2,344.23 / $3,388.44
| Professional | | $1,318.26 | $2,344.23 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,995.26 / $9,332.54
| Facility | | $1,148.15 | $1,995.26 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $1,122.02 / $1,862.09
| Professional | | $602.56 | $1,122.02 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,995.26 / $1,995.26 / $4,897.79
| Professional | | $1,995.26 | $1,995.26 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,511.89 / $4,466.84 / $4,897.79
| Professional | | $2,511.89 | $4,466.84 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,348.96 / $2,041.74
| Facility | | $794.33 | $1,348.96 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $891.25 / $1,412.54
| Professional | | $645.65 | $891.25 | $1,412.54 |