- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $2,137.96 / $2,344.23
| Professional | | $1,230.27 | $2,137.96 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,344.23 / $2,344.23 / $2,818.38
| Facility | | $2,344.23 | $2,344.23 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $2,187.76 / $2,398.83
| Professional | | $2,187.76 | $2,187.76 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,778.28 / $1,778.28
| Facility | | $1,258.93 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,288.25 / $2,238.72
| Professional | | $1,288.25 | $1,288.25 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,698.24 / $1,905.46
| Professional | | $1,584.89 | $1,698.24 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $2,398.83 / $4,168.69
| Facility | | $1,230.27 | $2,398.83 | $4,168.69 |
- 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
- $1,380.38 / $2,137.96 / $2,344.23
| Facility | | $1,380.38 | $2,137.96 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,412.54 / $2,187.76
| Professional | | $1,174.90 | $1,412.54 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $15,488.17 / $15,488.17 / $15,488.17
| Facility | | $15,488.17 | $15,488.17 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $18,197.01 / $18,197.01 / $26,915.35
| Professional | | $18,197.01 | $18,197.01 | $26,915.35 |