- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,691.53 / $2,691.53 / $2,691.53
| Facility | | $2,691.53 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $2,398.83 / $2,691.53
| Professional | | $1,548.82 | $2,398.83 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $2,754.23 / $3,311.31
| Professional | | $1,778.28 | $2,754.23 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,754.23 / $2,754.23 / $2,754.23
| Professional | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $2,137.96 / $2,238.72
| Facility | | $1,584.89 | $2,137.96 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,584.89 / $2,511.89
| Professional | | $1,584.89 | $1,584.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $1,819.70 / $2,570.40
| Professional | | $1,659.59 | $1,819.70 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $3,019.95 / $5,128.61
| Facility | | $1,513.56 | $3,019.95 | $5,128.61 |
- 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
- $1,445.44 / $2,570.40 / $2,951.21
| Facility | | $1,445.44 | $2,570.40 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,778.28 / $2,630.27
| Professional | | $1,445.44 | $1,778.28 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $18,197.01 / $18,197.01 / $18,197.01
| Facility | | $18,197.01 | $18,197.01 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19,952.62 / $19,952.62 / $28,183.83
| Professional | | $19,952.62 | $19,952.62 | $28,183.83 |