- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,548.82 / $1,548.82
| Facility | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,548.82 / $10,471.29
| Professional | | $912.01 | $1,548.82 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $2,344.23 / $2,398.83
| Professional | | $2,137.96 | $2,344.23 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $1,380.38 / $2,754.23
| Facility | | $1,380.38 | $1,380.38 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $2,818.38 / $4,168.69
| Professional | | $1,380.38 | $2,818.38 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $2,691.53 / $11,481.54
| Facility | | $1,548.82 | $2,691.53 | $11,481.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $1,445.44 / $2,398.83
| Professional | | $812.83 | $1,445.44 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,691.53 / $2,691.53 / $6,606.93
| Professional | | $2,691.53 | $2,691.53 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,388.44 / $6,025.60 / $6,606.93
| Professional | | $3,388.44 | $6,025.60 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,698.24 / $2,511.89
| Facility | | $1,445.44 | $1,698.24 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,202.26 / $1,905.46
| Professional | | $870.96 | $1,202.26 | $1,905.46 |