- 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
- $1,819.70 / $2,884.03 / $3,388.44
| Professional | | $1,819.70 | $2,884.03 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,467.37 / $3,467.37 / $4,168.69
| Facility | | $3,467.37 | $3,467.37 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,162.28 / $3,162.28 / $3,548.13
| Professional | | $3,162.28 | $3,162.28 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,862.09 / $3,019.95 / $3,019.95
| Facility | | $1,862.09 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $2,187.76 / $3,311.31
| Professional | | $2,187.76 | $2,187.76 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $2,089.30 / $3,019.95
| Professional | | $1,949.84 | $2,089.30 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $3,467.37 / $6,025.60
| Facility | | $1,819.70 | $3,467.37 | $6,025.60 |
- 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
- $2,041.74 / $3,162.28 / $3,388.44
| Facility | | $2,041.74 | $3,162.28 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $2,089.30 / $3,235.94
| Professional | | $1,737.80 | $2,089.30 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $22,387.21 / $22,387.21 / $22,387.21
| Facility | | $22,387.21 | $22,387.21 | $22,387.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $27,542.29 / $27,542.29 / $38,018.94
| Professional | | $27,542.29 | $27,542.29 | $38,018.94 |