- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5,128.61 / $5,128.61 / $5,128.61
| Facility | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,786.30 / $5,128.61 / $5,128.61
| Professional | | $4,786.30 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,511.89 / $5,011.87 / $8,511.38
| Facility | | $2,511.89 | $5,011.87 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,786.30 / $4,786.30 / $7,943.28
| Professional | | $4,786.30 | $4,786.30 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,786.30 / $4,786.30 / $4,786.30
| Professional | | $4,786.30 | $4,786.30 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5,370.32 / $10,000.00 / $12,882.50
| Facility | | $5,370.32 | $10,000.00 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,128.61 / $5,128.61 / $5,128.61
| Professional | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,897.79 / $5,754.40 / $6,918.31
| Professional | | $4,897.79 | $5,754.40 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5,128.61 / $6,025.60 / $8,709.64
| Facility | | $5,128.61 | $6,025.60 | $8,709.64 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,786.30 / $5,888.44 / $7,413.10
| Facility | | $4,786.30 | $5,888.44 | $7,413.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,786.30 / $5,888.44 / $7,413.10
| Professional | | $4,786.30 | $5,888.44 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $2,511.89 / $6,025.60
| Facility | | $2,041.74 | $2,511.89 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,011.87 / $5,011.87 / $5,495.41
| Professional | | $5,011.87 | $5,011.87 | $5,495.41 |