- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,621.81 / $1,819.70
| Professional | | $933.25 | $1,621.81 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,778.28 / $2,137.96
| Facility | | $1,778.28 | $1,778.28 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $1,659.59 / $1,819.70
| Professional | | $1,659.59 | $1,659.59 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $1,584.89 / $1,584.89
| Facility | | $977.24 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,698.24
| Professional | | $1,174.90 | $1,174.90 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,288.25 / $1,513.56
| Professional | | $1,202.26 | $1,288.25 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,819.70 / $3,090.30
| Facility | | $912.01 | $1,819.70 | $3,090.30 |
- 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
- $1,071.52 / $1,621.81 / $1,778.28
| Facility | | $1,071.52 | $1,621.81 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,071.52 / $1,659.59
| Professional | | $912.01 | $1,071.52 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $11,748.98 / $11,748.98 / $11,748.98
| Facility | | $11,748.98 | $11,748.98 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $14,125.38 / $14,125.38 / $16,218.10
| Professional | | $14,125.38 | $14,125.38 | $16,218.10 |