- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,073.80 / $15,135.61 / $15,135.61
| Facility | | $4,073.80 | $15,135.61 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,073.80 / $4,168.69 / $4,786.30
| Professional | | $4,073.80 | $4,168.69 | $4,786.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,265.80 / $10,000.00 / $28,840.32
| Facility | | $4,265.80 | $10,000.00 | $28,840.32 |
- 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
- Facility
- Modifier
- Typical Low / Median / Typical High
- $15,135.61 / $15,135.61 / $15,135.61
| Facility | | $15,135.61 | $15,135.61 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22,908.68 / $22,908.68 / $22,908.68
| Professional | | $22,908.68 | $22,908.68 | $22,908.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,073.80 / $5,011.87 / $15,135.61
| Facility | | $4,073.80 | $5,011.87 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,073.80 / $4,168.69 / $4,677.35
| Professional | | $4,073.80 | $4,168.69 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,168.69 / $5,011.87 / $13,489.63
| Facility | | $4,168.69 | $5,011.87 | $13,489.63 |
- 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
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,897.79 / $7,585.78 / $7,585.78
| Facility | | $4,897.79 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,168.69 / $4,168.69 / $4,168.69
| Professional | | $4,168.69 | $4,168.69 | $4,168.69 |
- 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 |