- 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
- $4,073.80 / $4,168.69 / $4,265.80
| Professional | | $4,073.80 | $4,168.69 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $2,187.76 / $3,715.35
| Facility | | $1,096.48 | $2,187.76 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,073.80 / $4,073.80 / $6,760.83
| Professional | | $4,073.80 | $4,073.80 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,073.80 / $4,073.80 / $4,073.80
| Professional | | $4,073.80 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,466.84 / $8,511.38 / $10,715.19
| Facility | | $4,466.84 | $8,511.38 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,265.80 / $4,265.80 / $4,265.80
| Professional | | $4,265.80 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,073.80 / $4,786.30 / $6,760.83
| Professional | | $4,073.80 | $4,786.30 | $6,760.83 |
- 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
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,981.07 / $4,786.30 / $6,165.95
| Facility | | $3,981.07 | $4,786.30 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,981.07 / $4,786.30 / $6,165.95
| Professional | | $3,981.07 | $4,786.30 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,258.93 / $3,890.45
| Facility | | $1,023.29 | $1,258.93 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,168.69 / $4,168.69 / $5,011.87
| Professional | | $4,168.69 | $4,168.69 | $5,011.87 |