- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $1,096.48 / $7,244.36
| Professional | | $537.03 | $1,096.48 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $1,659.59 / $1,659.59
| Professional | | $1,513.56 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,318.26 / $1,905.46
| Facility | | $1,318.26 | $1,318.26 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $2,398.83 / $3,162.28
| Professional | | $1,318.26 | $2,398.83 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,905.46 / $8,511.38
| Facility | | $1,096.48 | $1,905.46 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $1,071.52 / $1,778.28
| Professional | | $575.44 | $1,071.52 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,862.09 / $1,905.46 / $4,570.88
| Professional | | $1,862.09 | $1,905.46 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $4,265.80 / $4,570.88
| Professional | | $2,398.83 | $4,265.80 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $1,230.27 / $1,905.46
| Facility | | $741.31 | $1,230.27 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $851.14 / $1,348.96
| Professional | | $616.60 | $851.14 | $1,348.96 |