- 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
- $1,202.26 / $1,698.24 / $2,137.96
| Professional | | $1,202.26 | $1,698.24 | $2,137.96 |
- 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 / $1,949.84 / $1,949.84
| Facility | | $1,258.93 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,445.44 / $2,187.76
| Professional | | $1,445.44 | $1,445.44 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,348.96 / $1,778.28
| Professional | | $1,230.27 | $1,348.96 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $2,290.87 / $3,981.07
| Facility | | $1,174.90 | $2,290.87 | $3,981.07 |
- 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
- $1,096.48 / $1,862.09 / $2,344.23
| Facility | | $1,096.48 | $1,862.09 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,412.54 / $1,995.26
| Professional | | $1,096.48 | $1,412.54 | $1,995.26 |
- 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
- $14,791.08 / $14,791.08 / $19,054.61
| Professional | | $14,791.08 | $14,791.08 | $19,054.61 |