- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,311.31 / $3,311.31 / $3,311.31
| Facility | | $3,311.31 | $3,311.31 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $3,311.31 / $3,715.35
| Professional | | $1,949.84 | $3,311.31 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,715.35 / $3,715.35 / $4,466.84
| Facility | | $3,715.35 | $3,715.35 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,388.44 / $3,388.44 / $3,801.89
| Professional | | $3,388.44 | $3,388.44 | $3,801.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,995.26 / $3,801.89 / $3,801.89
| Facility | | $1,995.26 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,754.23 / $2,754.23 / $3,801.89
| Professional | | $2,754.23 | $2,754.23 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,238.72 / $2,398.83 / $3,019.95
| Professional | | $2,238.72 | $2,398.83 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $3,715.35 / $6,606.93
| Facility | | $1,949.84 | $3,715.35 | $6,606.93 |
- 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
- $2,187.76 / $3,388.44 / $3,630.78
| Facility | | $2,187.76 | $3,388.44 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,862.09 / $2,238.72 / $3,467.37
| Professional | | $1,862.09 | $2,238.72 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $24,547.09 / $24,547.09 / $24,547.09
| Facility | | $24,547.09 | $24,547.09 | $24,547.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29,512.09 / $29,512.09 / $40,738.03
| Professional | | $29,512.09 | $29,512.09 | $40,738.03 |