- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $3,019.95 / $3,715.35
| Professional | | $2,137.96 | $3,019.95 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,073.80 / $4,073.80 / $4,897.79
| Facility | | $4,073.80 | $4,073.80 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,801.89 / $3,801.89 / $4,168.69
| Professional | | $3,801.89 | $3,801.89 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $2,818.38 / $2,818.38
| Facility | | $645.65 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $2,041.74 / $3,311.31
| Professional | | $2,041.74 | $2,041.74 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $2,511.89 / $3,235.94
| Professional | | $2,290.87 | $2,511.89 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $3,981.07 / $7,079.46
| Facility | | $2,089.30 | $3,981.07 | $7,079.46 |
- 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
- $1,819.70 / $3,311.31 / $4,073.80
| Facility | | $1,819.70 | $3,311.31 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $2,454.71 / $3,467.37
| Professional | | $1,949.84 | $2,454.71 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $23,442.29 / $23,442.29 / $23,442.29
| Facility | | $23,442.29 | $23,442.29 | $23,442.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25,118.86 / $25,118.86 / $36,307.81
| Professional | | $25,118.86 | $25,118.86 | $36,307.81 |