- 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 / $2,089.30 / $2,570.40
| Professional | | $1,479.11 | $2,089.30 | $2,570.40 |
- 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
- $741.31 / $2,238.72 / $2,238.72
| Facility | | $741.31 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,621.81 / $2,344.23
| Professional | | $1,621.81 | $1,621.81 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,737.80 / $2,238.72
| Professional | | $1,584.89 | $1,737.80 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $2,754.23 / $4,786.30
| Facility | | $1,445.44 | $2,754.23 | $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
- $1,258.93 / $2,290.87 / $2,818.38
| Facility | | $1,258.93 | $2,290.87 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,737.80 / $2,454.71
| Professional | | $1,348.96 | $1,737.80 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $16,218.10 / $16,218.10 / $16,218.10
| Facility | | $16,218.10 | $16,218.10 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $17,782.79 / $17,782.79 / $25,118.86
| Professional | | $17,782.79 | $17,782.79 | $25,118.86 |