- 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
- $870.96 / $2,041.74 / $15,488.17
| Professional | | $870.96 | $2,041.74 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,818.38 / $3,090.30 / $3,090.30
| Professional | | $2,818.38 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $2,290.87 / $3,548.13
| Facility | | $2,290.87 | $2,290.87 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $3,801.89 / $5,370.32
| Professional | | $2,290.87 | $3,801.89 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $3,467.37 / $14,125.38
| Facility | | $2,041.74 | $3,467.37 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,778.28 / $2,754.23
| Professional | | $1,071.52 | $1,778.28 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,467.37 / $3,548.13 / $8,511.38
| Professional | | $3,467.37 | $3,548.13 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,548.13 / $3,548.13 / $3,548.13
| Facility | | $3,548.13 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,466.84 / $7,943.28 / $8,511.38
| Professional | | $4,466.84 | $7,943.28 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $2,041.74 / $3,090.30
| Facility | | $1,778.28 | $2,041.74 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,584.89 / $2,511.89
| Professional | | $1,148.15 | $1,584.89 | $2,511.89 |