- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,862.09 / $1,862.09 / $1,862.09
| Facility | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,584.89 / $1,905.46
| Professional | | $1,096.48 | $1,584.89 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $1,949.84 / $2,137.96
| Professional | | $1,949.84 | $1,949.84 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,513.56 / $1,548.82
| Facility | | $1,122.02 | $1,513.56 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $1,949.84
| Professional | | $1,122.02 | $1,122.02 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,348.96 / $1,949.84
| Professional | | $1,230.27 | $1,348.96 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $2,137.96 / $3,715.35
| Facility | | $1,071.52 | $2,137.96 | $3,715.35 |
- 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 / $1,819.70 / $2,041.74
| Facility | | $1,202.26 | $1,819.70 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,258.93 / $1,862.09
| Professional | | $1,023.29 | $1,258.93 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $12,882.50 / $12,882.50 / $12,882.50
| Facility | | $12,882.50 | $12,882.50 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16,218.10 / $16,218.10 / $24,547.09
| Professional | | $16,218.10 | $16,218.10 | $24,547.09 |