- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,344.23 / $2,344.23 / $2,344.23
| Facility | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $2,238.72 / $2,511.89
| Professional | | $1,380.38 | $2,238.72 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,454.71 / $2,454.71 / $2,691.53
| Professional | | $2,454.71 | $2,454.71 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $2,454.71 / $2,454.71
| Facility | | $1,412.54 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $1,819.70 / $2,570.40
| Professional | | $1,819.70 | $1,819.70 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,698.24 / $2,398.83
| Professional | | $1,584.89 | $1,698.24 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $2,691.53 / $4,677.35
| Facility | | $1,318.26 | $2,691.53 | $4,677.35 |
- 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
- $1,548.82 / $2,398.83 / $2,570.40
| Facility | | $1,548.82 | $2,398.83 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,584.89 / $2,454.71
| Professional | | $1,318.26 | $1,584.89 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $16,982.44 / $16,982.44 / $16,982.44
| Facility | | $16,982.44 | $16,982.44 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19,498.45 / $19,498.45 / $25,703.96
| Professional | | $19,498.45 | $19,498.45 | $25,703.96 |