- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,862.09 / $1,862.09 / $1,862.09
| Facility | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,862.09 / $2,187.76
| Professional | | $1,778.28 | $1,862.09 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,778.28 / $3,311.31
| Professional | | $1,778.28 | $1,778.28 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,995.26 / $1,995.26 / $1,995.26
| Professional | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $3,715.35 / $4,677.35
| Facility | | $2,137.96 | $3,715.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,862.09 / $1,862.09 / $1,862.09
| Professional | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $2,290.87 / $2,570.40
| Professional | | $2,041.74 | $2,290.87 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $2,187.76 / $3,019.95
| Facility | | $1,819.70 | $2,187.76 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $2,187.76 / $2,187.76
| Professional | | $2,089.30 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $2,187.76 / $3,235.94
| Facility | | $2,041.74 | $2,187.76 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $2,187.76 / $3,235.94
| Professional | | $2,041.74 | $2,187.76 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,570.40 / $4,265.80 / $5,495.41
| Facility | | $2,570.40 | $4,265.80 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $2,187.76 / $2,290.87
| Professional | | $2,187.76 | $2,187.76 | $2,290.87 |