- 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
- $2,290.87 / $4,265.80 / $5,128.61
| Professional | | $2,290.87 | $4,265.80 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $4,265.80 / $7,943.28
| Facility | | $426.58 | $4,265.80 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $3,388.44 / $5,248.07
| Professional | | $478.63 | $3,388.44 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $2,187.76 / $3,630.78
| Facility | | $2,187.76 | $2,187.76 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $1,862.09 / $2,290.87
| Professional | | $354.81 | $1,862.09 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $2,238.72 / $4,466.84
| Facility | | $467.74 | $2,238.72 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $4,265.80 / $5,128.61
| Professional | | $2,290.87 | $4,265.80 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $2,511.89 / $3,388.44
| Professional | | $251.19 | $2,511.89 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,235.94 / $3,235.94 / $3,388.44
| Professional | | $3,235.94 | $3,235.94 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,890.45 / $4,677.35 / $4,786.30
| Professional | | $3,890.45 | $4,677.35 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $1,949.84 / $3,630.78
| Facility | | $199.53 | $1,949.84 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,238.72 / $2,398.83 / $3,630.78
| Professional | | $2,238.72 | $2,398.83 | $3,630.78 |