- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $2,290.87 / $2,691.53
| Professional | | $1,348.96 | $2,290.87 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,570.40 / $2,570.40 / $3,090.30
| Facility | | $2,570.40 | $2,570.40 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $2,398.83 / $2,630.27
| Professional | | $2,398.83 | $2,398.83 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $2,454.71 / $2,454.71
| Facility | | $1,380.38 | $2,454.71 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $1,819.70 / $2,511.89
| Professional | | $1,819.70 | $1,819.70 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,584.89 / $2,089.30
| Professional | | $1,445.44 | $1,584.89 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $2,630.27 / $4,570.88
| Facility | | $1,348.96 | $2,630.27 | $4,570.88 |
- 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 / $2,344.23 / $2,511.89
| Facility | | $1,513.56 | $2,344.23 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,548.82 / $2,398.83
| Professional | | $1,288.25 | $1,548.82 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $16,595.87 / $16,595.87 / $16,595.87
| Facility | | $16,595.87 | $16,595.87 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22,908.68 / $22,908.68 / $28,840.32
| Professional | | $22,908.68 | $22,908.68 | $28,840.32 |