- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $1,513.56 / $1,513.56
| Facility | | $851.14 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $2,344.23 / $2,398.83
| Professional | | $1,513.56 | $2,344.23 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,096.48 / $1,202.26
| Facility | | $1,023.29 | $1,096.48 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $2,691.53 / $2,691.53
| Professional | | $1,905.46 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,691.53 / $3,630.78 / $5,623.41
| Facility | | $2,691.53 | $3,630.78 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $2,398.83 / $2,398.83
| Professional | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,479.11 / $1,995.26 / $3,235.94
| Facility | | $1,479.11 | $1,995.26 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $1,905.46 / $1,905.46
| Professional | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,479.11 / $2,454.71 / $3,235.94
| Facility | | $1,479.11 | $2,454.71 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,479.11 / $2,818.38 / $2,818.38
| Professional | | $1,479.11 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $8,511.38 / $8,511.38 / $8,511.38
| Facility | | $8,511.38 | $8,511.38 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12,882.50 / $12,882.50 / $12,882.50
| Professional | | $12,882.50 | $12,882.50 | $12,882.50 |