- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,584.89 / $1,584.89
| Facility | | $1,584.89 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,348.96 / $1,584.89
| Professional | | $891.25 | $1,348.96 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,778.28 / $2,137.96
| Facility | | $1,778.28 | $1,778.28 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,621.81 / $1,819.70
| Professional | | $1,621.81 | $1,621.81 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,122.02 / $1,318.26
| Facility | | $954.99 | $1,122.02 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $831.76 / $1,445.44
| Professional | | $831.76 | $831.76 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $933.25 / $1,288.25
| Professional | | $870.96 | $933.25 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,737.80 / $2,951.21
| Facility | | $891.25 | $1,737.80 | $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
- $891.25 / $1,348.96 / $1,737.80
| Facility | | $891.25 | $1,348.96 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $1,071.52 / $1,513.56
| Professional | | $812.83 | $1,071.52 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $10,000.00 / $10,000.00 / $10,000.00
| Facility | | $10,000.00 | $10,000.00 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $11,748.98 / $11,748.98 / $15,848.93
| Professional | | $11,748.98 | $11,748.98 | $15,848.93 |