- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,570.40 / $2,570.40 / $2,570.40
| Facility | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,479.11 / $2,238.72 / $2,570.40
| Professional | | $1,479.11 | $2,238.72 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,818.38 / $2,818.38 / $3,388.44
| Facility | | $2,818.38 | $2,818.38 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,630.27 / $2,630.27 / $2,884.03
| Professional | | $2,630.27 | $2,630.27 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $2,570.40 / $2,570.40
| Facility | | $1,513.56 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,862.09 / $1,862.09 / $2,754.23
| Professional | | $1,862.09 | $1,862.09 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,862.09 / $1,995.26 / $2,137.96
| Professional | | $1,862.09 | $1,995.26 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $2,818.38 / $4,786.30
| Facility | | $1,445.44 | $2,818.38 | $4,786.30 |
- 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 / $2,398.83 / $2,818.38
| Facility | | $1,513.56 | $2,398.83 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,698.24 / $2,454.71
| Professional | | $1,348.96 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $17,378.01 / $17,378.01 / $17,378.01
| Facility | | $17,378.01 | $17,378.01 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21,877.62 / $21,877.62 / $25,703.96
| Professional | | $21,877.62 | $21,877.62 | $25,703.96 |