- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $1,819.70 / $1,819.70
| Facility | | $1,819.70 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,737.80 / $2,041.74
| Professional | | $1,071.52 | $1,737.80 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $2,041.74 / $2,454.71
| Facility | | $2,041.74 | $2,041.74 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,862.09 / $1,862.09 / $2,041.74
| Professional | | $1,862.09 | $1,862.09 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,778.28 / $1,778.28
| Facility | | $1,096.48 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,318.26 / $1,949.84
| Professional | | $1,318.26 | $1,318.26 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $1,513.56 / $1,621.81
| Professional | | $1,412.54 | $1,513.56 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $2,041.74 / $3,548.13
| Facility | | $1,071.52 | $2,041.74 | $3,548.13 |
- 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
- $1,202.26 / $1,862.09 / $1,995.26
| Facility | | $1,202.26 | $1,862.09 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,230.27 / $1,862.09
| Professional | | $1,023.29 | $1,230.27 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $13,182.57 / $13,182.57 / $13,182.57
| Facility | | $13,182.57 | $13,182.57 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15,848.93 / $15,848.93 / $24,547.09
| Professional | | $15,848.93 | $15,848.93 | $24,547.09 |