- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,162.28 / $3,162.28 / $3,162.28
| Facility | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $3,162.28 / $21,877.62
| Professional | | $1,445.44 | $3,162.28 | $21,877.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,365.16 / $4,786.30 / $4,786.30
| Professional | | $4,365.16 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,754.23 / $2,754.23 / $5,495.41
| Facility | | $2,754.23 | $2,754.23 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,754.23 / $5,370.32 / $8,511.38
| Professional | | $2,754.23 | $5,370.32 | $8,511.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,162.28 / $5,370.32 / $23,442.29
| Facility | | $3,162.28 | $5,370.32 | $23,442.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $2,951.21 / $4,897.79
| Professional | | $1,659.59 | $2,951.21 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,370.32 / $5,495.41 / $13,182.57
| Professional | | $5,370.32 | $5,495.41 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5,495.41 / $5,495.41 / $5,495.41
| Facility | | $5,495.41 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $6,918.31 / $12,302.69 / $13,182.57
| Professional | | $6,918.31 | $12,302.69 | $13,182.57 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,454.71 / $3,311.31 / $5,128.61
| Facility | | $2,454.71 | $3,311.31 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $2,454.71 / $3,890.45
| Professional | | $1,778.28 | $2,454.71 | $3,890.45 |