- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,148.15 / $1,621.81
| Professional | | $776.25 | $1,148.15 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $1,513.56 / $1,819.70
| Facility | | $1,513.56 | $1,513.56 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $1,412.54 / $1,548.82
| Professional | | $1,412.54 | $1,412.54 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $1,096.48 / $1,096.48
| Facility | | $346.74 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $1,174.90
| Professional | | $812.83 | $812.83 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $870.96 / $1,258.93
| Professional | | $812.83 | $870.96 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $1,621.81 / $2,691.53
| Facility | | $758.58 | $1,621.81 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $870.96 / $1,513.56
| Facility | | $588.84 | $870.96 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $912.01 / $1,318.26
| Professional | | $707.95 | $912.01 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $9,332.54 / $9,332.54 / $9,332.54
| Facility | | $9,332.54 | $9,332.54 | $9,332.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $11,220.18 / $11,220.18 / $16,218.10
| Professional | | $11,220.18 | $11,220.18 | $16,218.10 |