- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,348.96 / $1,348.96
| Facility | | $1,348.96 | $1,348.96 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,174.90 / $1,513.56
| Professional | | $776.25 | $1,174.90 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $1,380.38 / $1,548.82
| Professional | | $1,380.38 | $1,380.38 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $1,479.11 / $1,479.11
| Facility | | $812.83 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,071.52 / $1,513.56
| Professional | | $1,071.52 | $1,071.52 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $870.96 / $1,288.25
| Professional | | $812.83 | $870.96 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,513.56 / $2,630.27
| Facility | | $776.25 | $1,513.56 | $2,630.27 |
- 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
- $831.76 / $1,288.25 / $1,479.11
| Facility | | $831.76 | $1,288.25 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $912.01 / $1,318.26
| Professional | | $707.95 | $912.01 | $1,318.26 |
- 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
- $11,220.18 / $11,220.18 / $16,595.87
| Professional | | $11,220.18 | $11,220.18 | $16,595.87 |