- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,090.30 / $3,090.30 / $3,090.30
| Facility | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $2,630.27 / $3,090.30
| Professional | | $1,778.28 | $2,630.27 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,388.44 / $3,388.44 / $4,073.80
| Facility | | $3,388.44 | $3,388.44 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,162.28 / $3,162.28 / $3,467.37
| Professional | | $3,162.28 | $3,162.28 | $3,467.37 |
- 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
- $2,290.87 / $2,290.87 / $3,388.44
| Professional | | $2,290.87 | $2,290.87 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,570.40 / $2,754.23 / $2,951.21
| Professional | | $2,570.40 | $2,754.23 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $3,388.44 / $6,165.95
| Facility | | $1,737.80 | $3,388.44 | $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
- $1,698.24 / $3,090.30 / $3,388.44
| Facility | | $1,698.24 | $3,090.30 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $2,041.74 / $3,162.28
| Professional | | $1,698.24 | $2,041.74 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $20,892.96 / $20,892.96 / $20,892.96
| Facility | | $20,892.96 | $20,892.96 | $20,892.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $27,542.29 / $27,542.29 / $35,481.34
| Professional | | $27,542.29 | $27,542.29 | $35,481.34 |