- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,513.56 / $2,290.87
| Professional | | $1,071.52 | $1,513.56 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,995.26 / $1,995.26 / $2,187.76
| Professional | | $1,995.26 | $1,995.26 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,698.24 / $1,698.24
| Facility | | $1,174.90 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,230.27 / $1,819.70
| Professional | | $1,230.27 | $1,230.27 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,148.15 / $1,548.82
| Professional | | $1,071.52 | $1,148.15 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $2,290.87 / $3,630.78
| Facility | | $1,000.00 | $2,290.87 | $3,630.78 |
- 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
- $851.14 / $1,148.15 / $2,137.96
| Facility | | $851.14 | $1,148.15 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,288.25 / $1,819.70
| Professional | | $954.99 | $1,288.25 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $12,022.64 / $12,022.64 / $12,022.64
| Facility | | $12,022.64 | $12,022.64 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $14,791.08 / $14,791.08 / $16,982.44
| Professional | | $14,791.08 | $14,791.08 | $16,982.44 |