- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,584.89 / $1,584.89
| Facility | | $1,584.89 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,584.89 / $11,748.98
| Professional | | $794.33 | $1,584.89 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $2,398.83 / $2,454.71
| Professional | | $2,187.76 | $2,398.83 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $1,949.84 / $2,818.38
| Facility | | $1,949.84 | $1,949.84 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $3,467.37 / $4,677.35
| Professional | | $1,949.84 | $3,467.37 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $2,754.23 / $12,882.50
| Facility | | $1,584.89 | $2,754.23 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,548.82 / $2,630.27
| Professional | | $831.76 | $1,548.82 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,754.23 / $2,754.23 / $6,760.83
| Professional | | $2,754.23 | $2,754.23 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,818.38 / $2,818.38 / $2,818.38
| Facility | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,467.37 / $6,165.95 / $6,760.83
| Professional | | $3,467.37 | $6,165.95 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,862.09 / $2,818.38
| Facility | | $1,096.48 | $1,862.09 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,230.27 / $1,949.84
| Professional | | $891.25 | $1,230.27 | $1,949.84 |