- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,265.80 / $4,265.80 / $4,265.80
| Facility | | $4,265.80 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $4,265.80 / $30,199.52
| Professional | | $1,778.28 | $4,265.80 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,888.44 / $6,456.54 / $6,456.54
| Professional | | $5,888.44 | $6,456.54 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,073.80 / $4,073.80 / $7,413.10
| Facility | | $4,073.80 | $4,073.80 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,073.80 / $7,244.36 / $11,220.18
| Professional | | $4,073.80 | $7,244.36 | $11,220.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,265.80 / $7,244.36 / $29,512.09
| Facility | | $4,265.80 | $7,244.36 | $29,512.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,238.72 / $3,715.35 / $6,606.93
| Professional | | $2,238.72 | $3,715.35 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $7,244.36 / $7,413.10 / $17,782.79
| Professional | | $7,244.36 | $7,413.10 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $9,332.54 / $16,595.87 / $17,782.79
| Professional | | $9,332.54 | $16,595.87 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,715.35 / $4,265.80 / $6,456.54
| Facility | | $3,715.35 | $4,265.80 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $3,311.31 / $5,248.07
| Professional | | $2,398.83 | $3,311.31 | $5,248.07 |