- 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
- $1,778.28 / $2,570.40 / $3,162.28
| Professional | | $1,778.28 | $2,570.40 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,235.94 / $3,235.94 / $3,548.13
| Professional | | $3,235.94 | $3,235.94 | $3,548.13 |
- 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
- $2,398.83 / $2,398.83 / $3,388.44
| Professional | | $2,398.83 | $2,398.83 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,905.46 / $2,630.27
| Professional | | $1,778.28 | $1,905.46 | $2,630.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $3,548.13 / $6,165.95
| Facility | | $1,659.59 | $3,548.13 | $6,165.95 |
- 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
- $1,584.89 / $2,884.03 / $3,467.37
| Facility | | $1,584.89 | $2,884.03 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $2,089.30 / $2,951.21
| Professional | | $1,659.59 | $2,089.30 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $20,417.38 / $20,417.38 / $20,417.38
| Facility | | $20,417.38 | $20,417.38 | $20,417.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30,902.95 / $30,902.95 / $30,902.95
| Professional | | $30,902.95 | $30,902.95 | $30,902.95 |