- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $1,513.56 / $1,513.56
| Facility | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $1,513.56 / $10,471.29
| Professional | | $588.84 | $1,513.56 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $2,290.87 / $2,290.87
| Professional | | $2,089.30 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $2,630.27
| Facility | | $1,122.02 | $1,122.02 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $2,691.53 / $3,981.07
| Professional | | $1,122.02 | $2,691.53 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $2,570.40 / $9,772.37
| Facility | | $1,348.96 | $2,570.40 | $9,772.37 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,202.26 / $2,344.23
| Professional | | $794.33 | $1,202.26 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,630.27 / $2,630.27 / $6,309.57
| Professional | | $2,630.27 | $2,630.27 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,630.27 / $2,630.27 / $2,630.27
| Facility | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,311.31 / $5,888.44 / $6,309.57
| Professional | | $3,311.31 | $5,888.44 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,348.96 / $2,089.30
| Facility | | $1,047.13 | $1,348.96 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $1,174.90 / $1,862.09
| Professional | | $812.83 | $1,174.90 | $1,862.09 |