- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $2,398.83 / $16,218.10
| Professional | | $1,096.48 | $2,398.83 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,311.31 / $3,630.78 / $3,715.35
| Professional | | $3,311.31 | $3,630.78 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,454.71 / $2,454.71 / $4,265.80
| Facility | | $2,454.71 | $2,454.71 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,454.71 / $4,365.16 / $6,456.54
| Professional | | $2,454.71 | $4,365.16 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $4,168.69 / $17,782.79
| Facility | | $2,398.83 | $4,168.69 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $2,238.72 / $3,801.89
| Professional | | $1,258.93 | $2,238.72 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,168.69 / $4,168.69 / $10,232.93
| Professional | | $4,168.69 | $4,168.69 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,265.80 / $4,265.80 / $4,265.80
| Facility | | $4,265.80 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,248.07 / $9,549.93 / $10,232.93
| Professional | | $5,248.07 | $9,549.93 | $10,232.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,238.72 / $2,630.27 / $3,890.45
| Facility | | $2,238.72 | $2,630.27 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $1,905.46 / $2,951.21
| Professional | | $1,380.38 | $1,905.46 | $2,951.21 |