- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,174.90 / $1,659.59
| Professional | | $891.25 | $1,174.90 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $1,819.70 / $2,187.76
| Facility | | $1,819.70 | $1,819.70 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $1,698.24 / $1,862.09
| Professional | | $1,698.24 | $1,698.24 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $1,318.26 / $1,348.96
| Facility | | $977.24 | $1,318.26 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $954.99 / $1,412.54
| Professional | | $954.99 | $954.99 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $933.25 / $1,258.93
| Professional | | $870.96 | $933.25 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,698.24 / $2,951.21
| Facility | | $891.25 | $1,698.24 | $2,951.21 |
- 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
- $741.31 / $1,348.96 / $1,819.70
| Facility | | $741.31 | $1,348.96 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $1,096.48 / $1,548.82
| Professional | | $851.14 | $1,096.48 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $9,549.93 / $9,549.93 / $9,549.93
| Facility | | $9,549.93 | $9,549.93 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $11,481.54 / $11,481.54 / $17,782.79
| Professional | | $11,481.54 | $11,481.54 | $17,782.79 |