- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,677.35 / $4,677.35 / $4,677.35
| Facility | | $4,677.35 | $4,677.35 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,951.21 / $4,677.35 / $6,606.93
| Professional | | $2,951.21 | $4,677.35 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $7,413.10 / $9,549.93
| Facility | | $954.99 | $7,413.10 | $9,549.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $4,466.84 / $6,606.93
| Professional | | $630.96 | $4,466.84 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,630.78 / $3,630.78 / $3,801.89
| Facility | | $3,630.78 | $3,630.78 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $3,090.30 / $3,630.78
| Professional | | $407.38 | $3,090.30 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $2,951.21 / $4,897.79
| Facility | | $602.56 | $2,951.21 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,951.21 / $4,677.35 / $6,606.93
| Professional | | $2,951.21 | $4,677.35 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $416.87 / $4,265.80
| Professional | | $416.87 | $416.87 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,168.69 / $4,168.69 / $4,466.84
| Professional | | $4,168.69 | $4,168.69 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,019.95 / $4,073.80 / $4,073.80
| Professional | | $3,019.95 | $4,073.80 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $1,258.93 / $2,951.21
| Facility | | $199.53 | $1,258.93 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,819.70 / $2,951.21
| Professional | | $1,548.82 | $1,819.70 | $2,951.21 |