- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $2,041.74 / $14,791.08
| Professional | | $1,023.29 | $2,041.74 | $14,791.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,818.38 / $3,090.30 / $3,162.28
| Professional | | $2,818.38 | $3,090.30 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $2,398.83 / $3,630.78
| Facility | | $2,398.83 | $2,398.83 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $4,365.16 / $6,025.60
| Professional | | $2,398.83 | $4,365.16 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $3,630.78 / $16,218.10
| Facility | | $2,041.74 | $3,630.78 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,995.26 / $3,388.44
| Professional | | $1,071.52 | $1,995.26 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,548.13 / $3,548.13 / $8,709.64
| Professional | | $3,548.13 | $3,548.13 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,466.84 / $8,128.31 / $8,709.64
| Professional | | $4,466.84 | $8,128.31 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $2,398.83 / $3,630.78
| Facility | | $1,445.44 | $2,398.83 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,621.81 / $2,511.89
| Professional | | $1,174.90 | $1,621.81 | $2,511.89 |