- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $1,318.26 / $1,995.26
| Professional | | $977.24 | $1,318.26 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $1,905.46 / $2,290.87
| Facility | | $1,905.46 | $1,905.46 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $1,737.80 / $1,949.84
| Professional | | $1,737.80 | $1,737.80 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,548.82 / $1,548.82
| Facility | | $1,023.29 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $1,659.59
| Professional | | $1,122.02 | $1,122.02 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,258.93 / $1,348.96
| Professional | | $1,148.15 | $1,258.93 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,995.26 / $3,162.28
| Facility | | $870.96 | $1,995.26 | $3,162.28 |
- 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
- $758.58 / $1,000.00 / $1,862.09
| Facility | | $758.58 | $1,000.00 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,122.02 / $1,621.81
| Professional | | $831.76 | $1,122.02 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15,488.17 / $15,488.17 / $15,488.17
| Professional | | $15,488.17 | $15,488.17 | $15,488.17 |