- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,388.44 / $3,388.44 / $3,388.44
| Facility | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $2,691.53 / $3,388.44
| Professional | | $1,949.84 | $2,691.53 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,467.37 / $3,467.37 / $3,890.45
| Professional | | $3,467.37 | $3,467.37 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,951.21 / $2,951.21 / $2,951.21
| Facility | | $2,951.21 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $2,137.96 / $3,162.28
| Professional | | $2,137.96 | $2,137.96 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $2,290.87 / $3,019.95
| Professional | | $2,137.96 | $2,290.87 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $3,715.35 / $6,918.31
| Facility | | $1,621.81 | $3,715.35 | $6,918.31 |
- 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
- $1,698.24 / $3,019.95 / $3,715.35
| Facility | | $1,698.24 | $3,019.95 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $2,290.87 / $3,235.94
| Professional | | $1,778.28 | $2,290.87 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $21,379.62 / $21,379.62 / $21,379.62
| Facility | | $21,379.62 | $21,379.62 | $21,379.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $23,442.29 / $23,442.29 / $33,113.11
| Professional | | $23,442.29 | $23,442.29 | $33,113.11 |