- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,090.30 / $3,090.30 / $3,090.30
| Facility | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $2,290.87 / $3,090.30
| Professional | | $1,548.82 | $2,290.87 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,691.53 / $2,691.53 / $2,951.21
| Professional | | $2,691.53 | $2,691.53 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $2,511.89 / $2,511.89
| Facility | | $1,584.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $1,819.70 / $2,754.23
| Professional | | $1,819.70 | $1,819.70 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $2,089.30 / $2,511.89
| Professional | | $1,949.84 | $2,089.30 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,479.11 / $3,162.28 / $5,248.07
| Facility | | $1,479.11 | $3,162.28 | $5,248.07 |
- 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
- $1,318.26 / $1,778.28 / $2,884.03
| Facility | | $1,318.26 | $1,778.28 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,778.28 / $2,630.27
| Professional | | $1,348.96 | $1,778.28 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19,054.61 / $19,054.61 / $19,054.61
| Facility | | $19,054.61 | $19,054.61 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28,840.32 / $28,840.32 / $28,840.32
| Professional | | $28,840.32 | $28,840.32 | $28,840.32 |