- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $1,819.70 / $1,819.70
| Facility | | $1,819.70 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,819.70 / $12,022.64
| Professional | | $1,047.13 | $1,819.70 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,511.89 / $2,754.23 / $2,754.23
| Professional | | $2,511.89 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,584.89 / $3,162.28
| Facility | | $1,584.89 | $1,584.89 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $3,311.31 / $4,897.79
| Professional | | $1,584.89 | $3,311.31 | $4,897.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $3,090.30 / $13,182.57
| Facility | | $1,819.70 | $3,090.30 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,698.24 / $2,754.23
| Professional | | $933.25 | $1,698.24 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,090.30 / $3,090.30 / $7,585.78
| Professional | | $3,090.30 | $3,090.30 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,890.45 / $7,079.46 / $7,585.78
| Professional | | $3,890.45 | $7,079.46 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $1,949.84 / $2,951.21
| Facility | | $1,659.59 | $1,949.84 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,412.54 / $2,187.76
| Professional | | $1,023.29 | $1,412.54 | $2,187.76 |