- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,479.11 / $1,479.11 / $1,479.11
| Facility | | $1,479.11 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $1,230.27 / $1,479.11
| Professional | | $851.14 | $1,230.27 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,548.82 / $1,698.24
| Professional | | $1,548.82 | $1,548.82 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,584.89 / $1,584.89
| Facility | | $891.25 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,148.15 / $1,698.24
| Professional | | $1,148.15 | $1,148.15 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,096.48 / $1,230.27
| Professional | | $1,023.29 | $1,096.48 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,621.81 / $2,754.23
| Facility | | $794.33 | $1,621.81 | $2,754.23 |
- 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
- $891.25 / $1,380.38 / $1,621.81
| Facility | | $891.25 | $1,380.38 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,000.00 / $1,412.54
| Professional | | $776.25 | $1,000.00 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $9,772.37 / $9,772.37 / $9,772.37
| Facility | | $9,772.37 | $9,772.37 | $9,772.37 |
- 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 |