- 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
- $1,479.11 / $2,238.72 / $2,511.89
| Professional | | $1,479.11 | $2,238.72 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,818.38 / $2,818.38 / $3,388.44
| Facility | | $2,818.38 | $2,818.38 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,570.40 / $2,570.40 / $2,818.38
| Professional | | $2,570.40 | $2,570.40 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $2,398.83 / $2,398.83
| Facility | | $1,513.56 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $1,737.80 / $2,570.40
| Professional | | $1,737.80 | $1,737.80 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $2,238.72 / $2,344.23
| Professional | | $2,089.30 | $2,238.72 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $2,818.38 / $4,786.30
| Facility | | $1,412.54 | $2,818.38 | $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
- $1,445.44 / $2,570.40 / $2,754.23
| Facility | | $1,445.44 | $2,570.40 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $1,698.24 / $2,630.27
| Professional | | $1,412.54 | $1,698.24 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $16,982.44 / $16,982.44 / $16,982.44
| Facility | | $16,982.44 | $16,982.44 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22,908.68 / $22,908.68 / $27,542.29
| Professional | | $22,908.68 | $22,908.68 | $27,542.29 |