- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $2,754.23 / $18,620.87
| Professional | | $1,258.93 | $2,754.23 | $18,620.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,162.28 / $3,162.28 / $3,715.35
| Professional | | $3,162.28 | $3,162.28 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,801.89 / $4,265.80 / $4,265.80
| Professional | | $3,801.89 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,454.71 / $2,454.71 / $4,897.79
| Facility | | $2,454.71 | $2,454.71 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,454.71 / $5,128.61 / $7,585.78
| Professional | | $2,454.71 | $5,128.61 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,754.23 / $4,786.30 / $20,417.38
| Facility | | $2,754.23 | $4,786.30 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $2,630.27 / $4,365.16
| Professional | | $1,445.44 | $2,630.27 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,786.30 / $4,786.30 / $11,748.98
| Professional | | $4,786.30 | $4,786.30 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,897.79 / $4,897.79 / $4,897.79
| Facility | | $4,897.79 | $4,897.79 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $6,025.60 / $10,964.78 / $11,748.98
| Professional | | $6,025.60 | $10,964.78 | $11,748.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,570.40 / $3,019.95 / $4,570.88
| Facility | | $2,570.40 | $3,019.95 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $2,187.76 / $3,388.44
| Professional | | $1,584.89 | $2,187.76 | $3,388.44 |