- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,511.89 / $2,511.89 / $2,511.89
| Facility | | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $2,511.89 / $19,054.61
| Professional | | $1,047.13 | $2,511.89 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,467.37 / $3,801.89 / $3,801.89
| Professional | | $3,467.37 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,691.53 / $2,691.53 / $4,365.16
| Facility | | $2,691.53 | $2,691.53 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,691.53 / $4,570.88 / $6,606.93
| Professional | | $2,691.53 | $4,570.88 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,454.71 / $4,265.80 / $17,378.01
| Facility | | $2,454.71 | $4,265.80 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $2,187.76 / $3,890.45
| Professional | | $1,318.26 | $2,187.76 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,265.80 / $4,265.80 / $10,471.29
| Professional | | $4,265.80 | $4,265.80 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,365.16 / $4,365.16 / $4,365.16
| Facility | | $4,365.16 | $4,365.16 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,495.41 / $9,772.37 / $10,471.29
| Professional | | $5,495.41 | $9,772.37 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,862.09 / $2,454.71 / $3,801.89
| Facility | | $1,862.09 | $2,454.71 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $1,949.84 / $3,090.30
| Professional | | $1,412.54 | $1,949.84 | $3,090.30 |