- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,630.27 / $2,630.27 / $2,630.27
| Facility | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,862.09 / $2,630.27
| Professional | | $1,288.25 | $1,862.09 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,511.89 / $2,511.89 / $3,019.95
| Facility | | $2,511.89 | $2,511.89 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $2,290.87 / $2,570.40
| Professional | | $2,290.87 | $2,290.87 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,819.70 / $1,862.09
| Facility | | $1,348.96 | $1,819.70 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,318.26 / $2,344.23
| Professional | | $1,318.26 | $1,318.26 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,548.82 / $1,949.84
| Professional | | $1,445.44 | $1,548.82 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $2,630.27 / $4,466.84
| Facility | | $1,258.93 | $2,630.27 | $4,466.84 |
- 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
- $1,096.48 / $1,445.44 / $2,454.71
| Facility | | $1,096.48 | $1,445.44 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,479.11 / $2,187.76
| Professional | | $1,148.15 | $1,479.11 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $15,488.17 / $15,488.17 / $15,488.17
| Facility | | $15,488.17 | $15,488.17 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19,498.45 / $19,498.45 / $22,387.21
| Professional | | $19,498.45 | $19,498.45 | $22,387.21 |