- 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
- $1,819.70 / $2,754.23 / $3,162.28
| Professional | | $1,819.70 | $2,754.23 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,467.37 / $3,467.37 / $4,168.69
| Facility | | $3,467.37 | $3,467.37 | $4,168.69 |
- 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
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,995.26 / $1,995.26 / $2,818.38
| Professional | | $1,995.26 | $1,995.26 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,630.27 / $2,818.38 / $3,019.95
| Professional | | $2,630.27 | $2,818.38 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $3,467.37 / $6,165.95
| Facility | | $1,737.80 | $3,467.37 | $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
- $1,737.80 / $3,162.28 / $3,467.37
| Facility | | $1,737.80 | $3,162.28 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $2,089.30 / $3,235.94
| Professional | | $1,737.80 | $2,089.30 | $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
- $28,183.83 / $28,183.83 / $33,113.11
| Professional | | $28,183.83 | $28,183.83 | $33,113.11 |