- 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
- $2,630.27 / $4,786.30 / $5,754.40
| Professional | | $2,630.27 | $4,786.30 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $4,786.30 / $8,511.38
| Facility | | $478.63 | $4,786.30 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $3,981.07 / $5,623.41
| Professional | | $537.03 | $3,981.07 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,235.94 / $3,235.94 / $3,981.07
| Facility | | $3,235.94 | $3,235.94 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $2,754.23 / $3,235.94
| Professional | | $416.87 | $2,754.23 | $3,235.94 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $1,995.26 / $4,365.16
| Facility | | $512.86 | $1,995.26 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,630.27 / $4,786.30 / $5,754.40
| Professional | | $2,630.27 | $4,786.30 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $2,818.38 / $3,801.89
| Professional | | $281.84 | $2,818.38 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,715.35 / $3,715.35 / $3,981.07
| Professional | | $3,715.35 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,981.07 / $5,370.32 / $5,370.32
| Professional | | $3,981.07 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $2,089.30 / $4,073.80
| Facility | | $223.87 | $2,089.30 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $2,630.27 / $4,073.80
| Professional | | $2,398.83 | $2,630.27 | $4,073.80 |