- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,570.40 / $2,570.40 / $2,570.40
| Facility | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,479.11 / $2,344.23 / $2,818.38
| Professional | | $1,479.11 | $2,344.23 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $2,630.27 / $3,162.28
| Professional | | $1,659.59 | $2,630.27 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,818.38 / $2,818.38 / $3,388.44
| Facility | | $2,818.38 | $2,818.38 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,630.27 / $2,630.27 / $2,630.27
| Professional | | $2,630.27 | $2,630.27 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $2,398.83 / $2,398.83
| Facility | | $1,548.82 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $1,737.80 / $2,754.23
| Professional | | $1,737.80 | $1,737.80 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,737.80 / $2,290.87
| Professional | | $1,584.89 | $1,737.80 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $2,818.38 / $4,897.79
| Facility | | $1,445.44 | $2,818.38 | $4,897.79 |
- 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
- $1,380.38 / $2,454.71 / $2,818.38
| Facility | | $1,380.38 | $2,454.71 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $1,698.24 / $2,511.89
| Professional | | $1,380.38 | $1,698.24 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $17,378.01 / $17,378.01 / $17,378.01
| Facility | | $17,378.01 | $17,378.01 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21,877.62 / $21,877.62 / $25,118.86
| Professional | | $21,877.62 | $21,877.62 | $25,118.86 |