- 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
- $1,174.90 / $2,570.40 / $17,378.01
| Professional | | $1,174.90 | $2,570.40 | $17,378.01 |
- 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
- $2,290.87 / $2,290.87 / $4,570.88
| Facility | | $2,290.87 | $2,290.87 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $4,677.35 / $7,079.46
| Professional | | $2,290.87 | $4,677.35 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,570.40 / $4,466.84 / $19,054.61
| Facility | | $2,570.40 | $4,466.84 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $2,454.71 / $4,073.80
| Professional | | $1,348.96 | $2,454.71 | $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
- $1,995.26 / $2,754.23 / $4,265.80
| Facility | | $1,995.26 | $2,754.23 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,995.26 / $3,162.28
| Professional | | $1,445.44 | $1,995.26 | $3,162.28 |