- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,995.26 / $1,995.26 / $1,995.26
| Facility | | $1,995.26 | $1,995.26 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,513.56 / $1,995.26
| Professional | | $1,122.02 | $1,513.56 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $2,187.76 / $2,630.27
| Facility | | $2,187.76 | $2,187.76 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $2,041.74 / $2,041.74
| Professional | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,737.80 / $1,737.80
| Facility | | $1,174.90 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,288.25 / $1,862.09
| Professional | | $1,288.25 | $1,288.25 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,318.26 / $1,548.82
| Professional | | $1,230.27 | $1,318.26 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $2,137.96 / $3,630.78
| Facility | | $1,096.48 | $2,137.96 | $3,630.78 |
- 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
- $977.24 / $1,698.24 / $2,187.76
| Facility | | $977.24 | $1,698.24 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,318.26 / $1,862.09
| Professional | | $1,023.29 | $1,318.26 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $12,022.64 / $12,022.64 / $12,022.64
| Facility | | $12,022.64 | $12,022.64 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $13,182.57 / $13,182.57 / $16,982.44
| Professional | | $13,182.57 | $13,182.57 | $16,982.44 |