- 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
- $1,621.81 / $2,951.21 / $4,677.35
| Professional | | $1,621.81 | $2,951.21 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,090.30 / $3,090.30 / $3,090.30
| Professional | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10,715.19 / $12,882.50 / $14,454.40
| Professional | | $10,715.19 | $12,882.50 | $14,454.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $467.74 / $3,090.30
| Facility | | $446.68 | $467.74 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $1,621.81 / $4,677.35
| Professional | | $446.68 | $1,621.81 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $4,677.35 / $10,000.00
| Facility | | $575.44 | $4,677.35 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $741.31 / $10,000.00
| Professional | | $501.19 | $741.31 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $1,737.80 / $4,677.35
| Facility | | $354.81 | $1,737.80 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $3,090.30 / $3,630.78
| Professional | | $79.43 | $3,090.30 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,466.84 / $6,025.60 / $6,606.93
| Professional | | $4,466.84 | $6,025.60 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $1,288.25 / $2,951.21
| Facility | | $229.09 | $1,288.25 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,862.09 / $3,388.44
| Professional | | $1,584.89 | $1,862.09 | $3,388.44 |