- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,511.89 / $2,511.89 / $2,511.89
| Facility | | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,548.82 / $2,511.89
| Professional | | $1,122.02 | $1,548.82 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,344.23 / $2,344.23 / $2,818.38
| Facility | | $2,344.23 | $2,344.23 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $2,187.76 / $2,398.83
| Professional | | $2,187.76 | $2,187.76 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,548.82 / $1,778.28
| Facility | | $1,258.93 | $1,548.82 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $1,905.46
| Professional | | $1,122.02 | $1,122.02 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,258.93 / $1,584.89
| Professional | | $1,148.15 | $1,258.93 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $2,511.89 / $3,981.07
| Facility | | $1,023.29 | $2,511.89 | $3,981.07 |
- 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
- $891.25 / $1,174.90 / $2,344.23
| Facility | | $891.25 | $1,174.90 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $1,380.38 / $1,995.26
| Professional | | $977.24 | $1,380.38 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $12,589.25 / $12,589.25 / $12,589.25
| Facility | | $12,589.25 | $12,589.25 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15,488.17 / $15,488.17 / $17,782.79
| Professional | | $15,488.17 | $15,488.17 | $17,782.79 |