- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,570.40 / $2,570.40 / $2,570.40
| Facility | | $2,570.40 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $2,570.40 / $19,054.61
| Professional | | $1,047.13 | $2,570.40 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,548.13 / $3,890.45 / $3,981.07
| Professional | | $3,548.13 | $3,890.45 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $2,398.83 / $4,570.88
| Facility | | $2,398.83 | $2,398.83 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $4,466.84 / $6,918.31
| Professional | | $2,398.83 | $4,466.84 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,570.40 / $4,466.84 / $16,982.44
| Facility | | $2,570.40 | $4,466.84 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $2,290.87 / $4,073.80
| Professional | | $1,380.38 | $2,290.87 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,466.84 / $4,466.84 / $10,964.78
| Professional | | $4,466.84 | $4,466.84 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,570.88 / $4,570.88 / $4,570.88
| Facility | | $4,570.88 | $4,570.88 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,623.41 / $10,000.00 / $10,964.78
| Professional | | $5,623.41 | $10,000.00 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $2,454.71 / $3,801.89
| Facility | | $2,187.76 | $2,454.71 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,479.11 / $1,995.26 / $3,162.28
| Professional | | $1,479.11 | $1,995.26 | $3,162.28 |