- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,786.30 / $4,786.30 / $4,786.30
| Facility | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,691.53 / $3,890.45 / $4,786.30
| Professional | | $2,691.53 | $3,890.45 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5,248.07 / $5,248.07 / $6,309.57
| Facility | | $5,248.07 | $5,248.07 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,897.79 / $4,897.79 / $5,248.07
| Professional | | $4,897.79 | $4,897.79 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,801.89 / $3,801.89 / $3,801.89
| Facility | | $3,801.89 | $3,801.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,235.94 / $3,235.94 / $3,890.45
| Professional | | $3,235.94 | $3,235.94 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,951.21 / $3,162.28 / $4,168.69
| Professional | | $2,951.21 | $3,162.28 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,630.27 / $5,128.61 / $8,912.51
| Facility | | $2,630.27 | $5,128.61 | $8,912.51 |
- 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
- $2,398.83 / $4,265.80 / $5,248.07
| Facility | | $2,398.83 | $4,265.80 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,511.89 / $3,162.28 / $4,466.84
| Professional | | $2,511.89 | $3,162.28 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $28,183.83 / $28,183.83 / $28,183.83
| Facility | | $28,183.83 | $28,183.83 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33,113.11 / $33,113.11 / $46,773.51
| Professional | | $33,113.11 | $33,113.11 | $46,773.51 |