- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,388.44 / $3,388.44 / $3,388.44
| Facility | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $2,238.72 / $3,388.44
| Professional | | $1,621.81 | $2,238.72 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,235.94 / $3,235.94 / $3,801.89
| Facility | | $3,235.94 | $3,235.94 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,951.21 / $2,951.21 / $3,235.94
| Professional | | $2,951.21 | $2,951.21 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $2,344.23 / $2,344.23
| Facility | | $831.76 | $2,344.23 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $1,698.24 / $2,570.40
| Professional | | $1,698.24 | $1,698.24 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $1,949.84 / $2,511.89
| Professional | | $1,819.70 | $1,949.84 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $3,388.44 / $5,623.41
| Facility | | $1,584.89 | $3,388.44 | $5,623.41 |
- 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
- $1,174.90 / $1,737.80 / $3,162.28
| Facility | | $1,174.90 | $1,737.80 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,905.46 / $2,754.23
| Professional | | $1,445.44 | $1,905.46 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $18,197.01 / $18,197.01 / $18,197.01
| Facility | | $18,197.01 | $18,197.01 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19,952.62 / $19,952.62 / $28,183.83
| Professional | | $19,952.62 | $19,952.62 | $28,183.83 |