- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $1,148.15 / $1,659.59
| Professional | | $812.83 | $1,148.15 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,548.82 / $1,862.09
| Facility | | $1,548.82 | $1,548.82 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,445.44 / $1,584.89
| Professional | | $1,445.44 | $1,445.44 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $1,174.90 / $1,174.90
| Facility | | $398.11 | $1,174.90 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $870.96 / $1,258.93
| Professional | | $870.96 | $870.96 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $933.25 / $1,230.27
| Professional | | $870.96 | $933.25 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,659.59 / $2,754.23
| Facility | | $776.25 | $1,659.59 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $1,819.70 / $1,949.84
| Professional | | $0.60 | $1,819.70 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $891.25 / $1,548.82
| Facility | | $602.56 | $891.25 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $933.25 / $1,348.96
| Professional | | $724.44 | $933.25 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $9,549.93 / $9,549.93 / $9,549.93
| Facility | | $9,549.93 | $9,549.93 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12,022.64 / $12,022.64 / $13,803.84
| Professional | | $12,022.64 | $12,022.64 | $13,803.84 |