- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,862.09 / $2,137.96
| Professional | | $1,258.93 | $1,862.09 | $2,137.96 |
- 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
- $1,288.25 / $2,089.30 / $2,089.30
| Facility | | $1,288.25 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $1,513.56 / $2,187.76
| Professional | | $1,513.56 | $1,513.56 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,737.80 / $1,819.70
| Professional | | $1,621.81 | $1,737.80 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $2,344.23 / $3,981.07
| Facility | | $1,202.26 | $2,344.23 | $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
- $1,348.96 / $2,089.30 / $2,344.23
| Facility | | $1,348.96 | $2,089.30 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,445.44 / $2,137.96
| Professional | | $1,148.15 | $1,445.44 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $14,791.08 / $14,791.08 / $14,791.08
| Facility | | $14,791.08 | $14,791.08 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $17,378.01 / $17,378.01 / $21,877.62
| Professional | | $17,378.01 | $17,378.01 | $21,877.62 |