- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,884.03 / $2,884.03 / $2,884.03
| Facility | | $2,884.03 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $2,398.83 / $2,884.03
| Professional | | $1,659.59 | $2,398.83 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,162.28 / $3,162.28 / $3,801.89
| Facility | | $3,162.28 | $3,162.28 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,951.21 / $2,951.21 / $3,235.94
| Professional | | $2,951.21 | $2,951.21 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $2,398.83 / $2,398.83
| Facility | | $181.97 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $1,737.80 / $2,454.71
| Professional | | $323.59 | $1,737.80 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $2,884.03 / $5,370.32
| Facility | | $812.83 | $2,884.03 | $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
- $1,318.26 / $2,570.40 / $3,162.28
| Facility | | $1,318.26 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,905.46 / $2,818.38
| Professional | | $1,584.89 | $1,905.46 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $18,197.01 / $18,197.01 / $18,197.01
| Facility | | $18,197.01 | $18,197.01 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19,498.45 / $19,498.45 / $28,183.83
| Professional | | $19,498.45 | $19,498.45 | $28,183.83 |