- 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
- $1,122.02 / $2,511.89 / $16,595.87
| Professional | | $1,122.02 | $2,511.89 | $16,595.87 |
- 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
- $2,511.89 / $2,511.89 / $4,365.16
| Facility | | $2,511.89 | $2,511.89 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,511.89 / $4,570.88 / $6,760.83
| Professional | | $2,511.89 | $4,570.88 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,511.89 / $4,265.80 / $18,197.01
| Facility | | $2,511.89 | $4,265.80 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $2,290.87 / $3,890.45
| Professional | | $1,288.25 | $2,290.87 | $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
- $5,370.32 / $9,772.37 / $10,471.29
| Professional | | $5,370.32 | $9,772.37 | $10,471.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $2,691.53 / $4,073.80
| Facility | | $2,290.87 | $2,691.53 | $4,073.80 |
- 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 |