- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,584.89 / $1,584.89
| Facility | | $1,584.89 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,288.25 / $1,778.28
| Professional | | $891.25 | $1,288.25 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $1,737.80 / $2,089.30
| Facility | | $1,737.80 | $1,737.80 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,621.81 / $1,778.28
| Professional | | $1,621.81 | $1,621.81 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,621.81 / $1,621.81
| Facility | | $933.25 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,202.26 / $1,659.59
| Professional | | $1,202.26 | $1,202.26 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,148.15 / $1,380.38
| Professional | | $1,071.52 | $1,148.15 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,778.28 / $3,019.95
| Facility | | $870.96 | $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
- $1,000.00 / $1,548.82 / $1,737.80
| Facility | | $1,000.00 | $1,548.82 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $1,047.13 / $1,584.89
| Professional | | $851.14 | $1,047.13 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $10,964.78 / $10,964.78 / $10,964.78
| Facility | | $10,964.78 | $10,964.78 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $14,791.08 / $14,791.08 / $15,488.17
| Professional | | $14,791.08 | $14,791.08 | $15,488.17 |