- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,479.11 / $2,137.96
| Professional | | $1,174.90 | $1,479.11 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $2,137.96 / $2,137.96
| Professional | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,344.23 / $2,344.23 / $2,818.38
| Facility | | $2,344.23 | $2,344.23 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $2,187.76 / $2,398.83
| Professional | | $2,187.76 | $2,187.76 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,819.70 / $1,819.70
| Facility | | $1,288.25 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,318.26 / $2,187.76
| Professional | | $1,318.26 | $1,318.26 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,445.44 / $1,584.89
| Professional | | $1,348.96 | $1,445.44 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $2,187.76 / $3,801.89
| Facility | | $1,000.00 | $2,187.76 | $3,801.89 |
- 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
- $954.99 / $1,698.24 / $2,344.23
| Facility | | $954.99 | $1,698.24 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,412.54 / $1,995.26
| Professional | | $1,122.02 | $1,412.54 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $12,302.69 / $12,302.69 / $12,302.69
| Facility | | $12,302.69 | $12,302.69 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $14,791.08 / $14,791.08 / $16,982.44
| Professional | | $14,791.08 | $14,791.08 | $16,982.44 |