- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,778.28 / $2,187.76
| Professional | | $1,258.93 | $1,778.28 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,238.72 / $2,238.72 / $2,454.71
| Professional | | $2,238.72 | $2,238.72 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $2,398.83 / $2,398.83
| Facility | | $630.96 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,995.26 / $1,995.26 / $2,454.71
| Professional | | $1,995.26 | $1,995.26 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,445.44 / $1,995.26
| Professional | | $1,348.96 | $1,445.44 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $2,398.83 / $4,265.80
| Facility | | $1,230.27 | $2,398.83 | $4,265.80 |
- 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
- $707.95 / $1,778.28 / $2,398.83
| Facility | | $707.95 | $1,778.28 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,148.15 / $1,479.11 / $2,089.30
| Professional | | $1,148.15 | $1,479.11 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $14,125.38 / $14,125.38 / $14,125.38
| Facility | | $14,125.38 | $14,125.38 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16,218.10 / $16,218.10 / $24,547.09
| Professional | | $16,218.10 | $16,218.10 | $24,547.09 |