- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,995.26 / $2,290.87
| Professional | | $1,318.26 | $1,995.26 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,344.23 / $2,344.23 / $2,344.23
| Professional | | $2,344.23 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $2,238.72 / $2,238.72
| Facility | | $660.69 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $1,905.46 / $2,344.23
| Professional | | $1,905.46 | $1,905.46 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $1,513.56 / $2,344.23
| Professional | | $1,412.54 | $1,513.56 | $2,344.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $2,570.40 / $4,570.88
| Facility | | $1,288.25 | $2,570.40 | $4,570.88 |
- 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
- $776.25 / $1,949.84 / $2,511.89
| Facility | | $776.25 | $1,949.84 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,548.82 / $2,290.87
| Professional | | $1,230.27 | $1,548.82 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $15,488.17 / $15,488.17 / $15,488.17
| Facility | | $15,488.17 | $15,488.17 | $15,488.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $17,782.79 / $17,782.79 / $25,703.96
| Professional | | $17,782.79 | $17,782.79 | $25,703.96 |