- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $1,202.26 / $10,232.93
| Professional | | $562.34 | $1,202.26 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $1,819.70 / $1,819.70
| Professional | | $1,659.59 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $1,513.56 / $2,089.30
| Facility | | $1,513.56 | $1,513.56 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $2,630.27 / $3,388.44
| Professional | | $1,513.56 | $2,630.27 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $2,089.30 / $9,549.93
| Facility | | $1,202.26 | $2,089.30 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $1,174.90 / $1,862.09
| Professional | | $630.96 | $1,174.90 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $2,089.30 / $5,011.87
| Professional | | $2,041.74 | $2,089.30 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $2,089.30 / $2,089.30
| Facility | | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,630.27 / $4,677.35 / $5,011.87
| Professional | | $2,630.27 | $4,677.35 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,318.26 / $2,041.74
| Facility | | $1,148.15 | $1,318.26 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $933.25 / $1,479.11
| Professional | | $676.08 | $933.25 | $1,479.11 |