- 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 / $1,318.26 / $1,621.81
| Professional | | $933.25 | $1,318.26 | $1,621.81 |
- 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
- $467.74 / $1,202.26 / $1,202.26
| Facility | | $467.74 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $891.25 / $1,348.96
| Professional | | $891.25 | $891.25 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,096.48 / $1,412.54
| Professional | | $1,023.29 | $1,096.48 | $1,412.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,778.28 / $3,019.95
| Facility | | $912.01 | $1,778.28 | $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
- $812.83 / $1,445.44 / $1,778.28
| Facility | | $812.83 | $1,445.44 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $1,096.48 / $1,548.82
| Professional | | $851.14 | $1,096.48 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $10,232.93 / $10,232.93 / $10,232.93
| Facility | | $10,232.93 | $10,232.93 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12,022.64 / $12,022.64 / $15,848.93
| Professional | | $12,022.64 | $12,022.64 | $15,848.93 |