- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,801.89 / $3,801.89 / $3,801.89
| Facility | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $3,311.31 / $3,801.89
| Professional | | $2,187.76 | $3,311.31 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,168.69 / $4,168.69 / $5,011.87
| Facility | | $4,168.69 | $4,168.69 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,890.45 / $3,890.45 / $4,265.80
| Professional | | $3,890.45 | $3,890.45 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $3,548.13 / $3,548.13
| Facility | | $2,290.87 | $3,548.13 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,630.27 / $2,630.27 / $3,890.45
| Professional | | $2,630.27 | $2,630.27 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,238.72 / $2,398.83 / $3,388.44
| Professional | | $2,238.72 | $2,398.83 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $4,168.69 / $7,244.36
| Facility | | $2,137.96 | $4,168.69 | $7,244.36 |
- 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
- $2,344.23 / $3,630.78 / $4,168.69
| Facility | | $2,344.23 | $3,630.78 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,995.26 / $2,570.40 / $3,715.35
| Professional | | $1,995.26 | $2,570.40 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $26,302.68 / $26,302.68 / $26,302.68
| Facility | | $26,302.68 | $26,302.68 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45,708.82 / $45,708.82 / $45,708.82
| Professional | | $45,708.82 | $45,708.82 | $45,708.82 |