- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,148.15 / $1,148.15
| Facility | | $1,148.15 | $1,148.15 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $1,047.13 / $1,202.26
| Professional | | $660.69 | $1,047.13 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,288.25 / $1,513.56
| Facility | | $1,288.25 | $1,288.25 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,288.25
| Professional | | $1,174.90 | $1,174.90 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,258.93 / $1,258.93
| Facility | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $912.01 / $1,348.96
| Professional | | $912.01 | $912.01 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $851.14 / $1,202.26
| Professional | | $794.33 | $851.14 | $1,202.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $1,318.26 / $2,290.87
| Facility | | $630.96 | $1,318.26 | $2,290.87 |
- 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
- $645.65 / $1,148.15 / $1,258.93
| Facility | | $645.65 | $1,148.15 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $776.25 / $1,174.90
| Professional | | $645.65 | $776.25 | $1,174.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $8,317.64 / $8,317.64 / $8,317.64
| Facility | | $8,317.64 | $8,317.64 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $9,772.37 / $9,772.37 / $12,302.69
| Professional | | $9,772.37 | $9,772.37 | $12,302.69 |