- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,265.80 / $4,265.80 / $4,265.80
| Facility | | $4,265.80 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $4,265.80 / $30,199.52
| Professional | | $2,089.30 | $4,265.80 | $30,199.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,888.44 / $6,456.54 / $6,456.54
| Professional | | $5,888.44 | $6,456.54 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,466.84 / $4,466.84 / $7,413.10
| Facility | | $4,466.84 | $4,466.84 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,466.84 / $7,943.28 / $12,589.25
| Professional | | $4,466.84 | $7,943.28 | $12,589.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,265.80 / $7,413.10 / $33,884.42
| Facility | | $4,265.80 | $7,413.10 | $33,884.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $4,073.80 / $6,606.93
| Professional | | $2,187.76 | $4,073.80 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $7,244.36 / $7,244.36 / $17,782.79
| Professional | | $7,244.36 | $7,244.36 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $7,413.10 / $7,413.10 / $7,413.10
| Facility | | $7,413.10 | $7,413.10 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $9,120.11 / $16,595.87 / $17,782.79
| Professional | | $9,120.11 | $16,595.87 | $17,782.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,265.80 / $5,011.87 / $7,585.78
| Facility | | $4,265.80 | $5,011.87 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $3,311.31 / $5,128.61
| Professional | | $2,398.83 | $3,311.31 | $5,128.61 |