- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $2,691.53 / $3,311.31
| Professional | | $1,905.46 | $2,691.53 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,388.44 / $3,388.44 / $3,388.44
| Professional | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $3,090.30 / $3,090.30
| Facility | | $954.99 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,238.72 / $2,238.72 / $3,235.94
| Professional | | $2,238.72 | $2,238.72 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $2,238.72 / $2,884.03
| Professional | | $2,089.30 | $2,238.72 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,862.09 / $3,630.78 / $6,165.95
| Facility | | $1,862.09 | $3,630.78 | $6,165.95 |
- 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
- $1,659.59 / $2,951.21 / $3,630.78
| Facility | | $1,659.59 | $2,951.21 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $2,238.72 / $3,162.28
| Professional | | $1,737.80 | $2,238.72 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $20,892.96 / $20,892.96 / $20,892.96
| Facility | | $20,892.96 | $20,892.96 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22,908.68 / $22,908.68 / $32,359.37
| Professional | | $22,908.68 | $22,908.68 | $32,359.37 |