- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $1,071.52 / $1,202.26
| Professional | | $616.60 | $1,071.52 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,412.54
| Facility | | $1,174.90 | $1,174.90 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,096.48 / $1,202.26
| Professional | | $1,096.48 | $1,096.48 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $891.25 / $891.25
| Facility | | $630.96 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $660.69 / $912.01
| Professional | | $660.69 | $660.69 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $724.44 / $1,096.48
| Professional | | $660.69 | $724.44 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $1,230.27 / $2,089.30
| Facility | | $602.56 | $1,230.27 | $2,089.30 |
- 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
- $588.84 / $1,071.52 / $1,174.90
| Facility | | $588.84 | $1,071.52 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $707.95 / $1,096.48
| Professional | | $588.84 | $707.95 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $7,762.47 / $7,762.47 / $7,762.47
| Facility | | $7,762.47 | $7,762.47 | $7,762.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8,912.51 / $8,912.51 / $11,748.98
| Professional | | $8,912.51 | $8,912.51 | $11,748.98 |