- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $1,698.24 / $1,698.24
| Facility | | $1,698.24 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,230.27 / $1,698.24
| Professional | | $870.96 | $1,230.27 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,479.11 / $1,479.11 / $1,621.81
| Professional | | $1,479.11 | $1,479.11 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,412.54 / $1,412.54
| Facility | | $870.96 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,023.29 / $1,513.56
| Professional | | $1,023.29 | $1,023.29 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $1,047.13 / $1,412.54
| Professional | | $977.24 | $1,047.13 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $1,698.24 / $2,884.03
| Facility | | $851.14 | $1,698.24 | $2,884.03 |
- 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
- $724.44 / $977.24 / $1,584.89
| Facility | | $724.44 | $977.24 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $977.24 / $1,445.44
| Professional | | $741.31 | $977.24 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $10,471.29 / $10,471.29 / $10,471.29
| Facility | | $10,471.29 | $10,471.29 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12,589.25 / $12,589.25 / $18,620.87
| Professional | | $12,589.25 | $12,589.25 | $18,620.87 |