- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,019.95 / $3,019.95 / $3,019.95
| Facility | | $3,019.95 | $3,019.95 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $3,019.95 / $20,417.38
| Professional | | $1,659.59 | $3,019.95 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,168.69 / $4,570.88 / $4,570.88
| Professional | | $4,168.69 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,019.95 / $3,019.95 / $5,248.07
| Facility | | $3,019.95 | $3,019.95 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,019.95 / $5,888.44 / $7,943.28
| Professional | | $3,019.95 | $5,888.44 | $7,943.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,884.03 / $5,128.61 / $20,892.96
| Facility | | $2,884.03 | $5,128.61 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $2,630.27 / $3,890.45
| Professional | | $1,659.59 | $2,630.27 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,128.61 / $5,128.61 / $12,589.25
| Professional | | $5,128.61 | $5,128.61 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5,248.07 / $5,248.07 / $5,248.07
| Facility | | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $6,456.54 / $11,748.98 / $12,589.25
| Professional | | $6,456.54 | $11,748.98 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,630.27 / $3,019.95 / $4,570.88
| Facility | | $2,630.27 | $3,019.95 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $2,344.23 / $3,715.35
| Professional | | $1,698.24 | $2,344.23 | $3,715.35 |