- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $1,513.56 / $1,513.56
| Facility | | $1,513.56 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,318.26 / $1,621.81
| Professional | | $891.25 | $1,318.26 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $1,698.24 / $2,041.74
| Facility | | $1,698.24 | $1,698.24 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,548.82 / $1,737.80
| Professional | | $1,548.82 | $1,548.82 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,380.38 / $1,380.38
| Facility | | $912.01 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,000.00 / $1,548.82
| Professional | | $1,000.00 | $1,000.00 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,023.29 / $1,479.11
| Professional | | $954.99 | $1,023.29 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,698.24 / $3,019.95
| Facility | | $891.25 | $1,698.24 | $3,019.95 |
- 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
- $851.14 / $1,548.82 / $1,659.59
| Facility | | $851.14 | $1,548.82 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $1,023.29 / $1,584.89
| Professional | | $851.14 | $1,023.29 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $10,471.29 / $10,471.29 / $10,471.29
| Facility | | $10,471.29 | $10,471.29 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12,302.69 / $12,302.69 / $19,054.61
| Professional | | $12,302.69 | $12,302.69 | $19,054.61 |