- 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
- $1,621.81 / $2,754.23 / $3,162.28
| Professional | | $1,621.81 | $2,754.23 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,090.30 / $3,090.30 / $3,715.35
| Facility | | $3,090.30 | $3,090.30 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,818.38 / $2,818.38 / $2,818.38
| Professional | | $2,818.38 | $2,818.38 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $2,691.53 / $2,691.53
| Facility | | $1,659.59 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,995.26 / $1,995.26 / $2,951.21
| Professional | | $1,995.26 | $1,995.26 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $1,862.09 / $2,454.71
| Professional | | $1,737.80 | $1,862.09 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $3,090.30 / $5,370.32
| Facility | | $1,548.82 | $3,090.30 | $5,370.32 |
- 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
- $1,819.70 / $2,754.23 / $3,019.95
| Facility | | $1,819.70 | $2,754.23 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,862.09 / $2,818.38
| Professional | | $1,548.82 | $1,862.09 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19,952.62 / $19,952.62 / $19,952.62
| Facility | | $19,952.62 | $19,952.62 | $19,952.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25,118.86 / $25,118.86 / $28,183.83
| Professional | | $25,118.86 | $25,118.86 | $28,183.83 |