- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $1,819.70 / $1,819.70
| Facility | | $1,819.70 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $1,819.70 / $10,964.78
| Professional | | $741.31 | $1,819.70 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,511.89 / $2,754.23 / $2,754.23
| Professional | | $2,511.89 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $1,949.84 / $3,162.28
| Facility | | $1,949.84 | $1,949.84 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $3,548.13 / $4,786.30
| Professional | | $1,949.84 | $3,548.13 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $3,090.30 / $12,022.64
| Facility | | $1,819.70 | $3,090.30 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,548.82 / $2,818.38
| Professional | | $933.25 | $1,548.82 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,090.30 / $3,090.30 / $7,585.78
| Professional | | $3,090.30 | $3,090.30 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,890.45 / $7,079.46 / $7,585.78
| Professional | | $3,890.45 | $7,079.46 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,737.80 / $2,691.53
| Facility | | $1,096.48 | $1,737.80 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,412.54 / $2,187.76
| Professional | | $1,023.29 | $1,412.54 | $2,187.76 |