- 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 / $3,162.28 / $3,801.89
| Professional | | $2,187.76 | $3,162.28 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,265.80 / $4,265.80 / $5,128.61
| Facility | | $4,265.80 | $4,265.80 | $5,128.61 |
- 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
- $1,096.48 / $3,311.31 / $3,311.31
| Facility | | $1,096.48 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $2,398.83 / $3,548.13
| Professional | | $2,398.83 | $2,398.83 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $2,570.40 / $3,311.31
| Professional | | $2,398.83 | $2,570.40 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $4,168.69 / $7,079.46
| Facility | | $2,089.30 | $4,168.69 | $7,079.46 |
- 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
- $1,905.46 / $3,388.44 / $4,168.69
| Facility | | $1,905.46 | $3,388.44 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,995.26 / $2,570.40 / $3,630.78
| Professional | | $1,995.26 | $2,570.40 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $23,988.33 / $23,988.33 / $23,988.33
| Facility | | $23,988.33 | $23,988.33 | $23,988.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26,302.68 / $26,302.68 / $37,153.52
| Professional | | $26,302.68 | $26,302.68 | $37,153.52 |