- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $2,570.40 / $3,019.95
| Professional | | $1,778.28 | $2,570.40 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,388.44 / $3,388.44 / $4,073.80
| Facility | | $3,388.44 | $3,388.44 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,090.30 / $3,090.30 / $3,467.37
| Professional | | $3,090.30 | $3,090.30 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $2,290.87 / $2,290.87
| Facility | | $870.96 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $1,659.59 / $2,511.89
| Professional | | $1,659.59 | $1,659.59 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $2,041.74 / $2,630.27
| Professional | | $1,905.46 | $2,041.74 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $3,311.31 / $5,754.40
| Facility | | $1,698.24 | $3,311.31 | $5,754.40 |
- 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
- $1,513.56 / $2,754.23 / $3,311.31
| Facility | | $1,513.56 | $2,754.23 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $2,041.74 / $2,884.03
| Professional | | $1,584.89 | $2,041.74 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19,498.45 / $19,498.45 / $19,498.45
| Facility | | $19,498.45 | $19,498.45 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20,892.96 / $20,892.96 / $30,199.52
| Professional | | $20,892.96 | $20,892.96 | $30,199.52 |