- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $3,715.35 / $26,915.35
| Professional | | $2,137.96 | $3,715.35 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,128.61 / $5,623.41 / $5,754.40
| Professional | | $5,128.61 | $5,623.41 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,715.35 / $3,715.35 / $6,606.93
| Facility | | $3,715.35 | $3,715.35 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,715.35 / $6,606.93 / $10,000.00
| Professional | | $3,715.35 | $6,606.93 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,715.35 / $6,456.54 / $26,915.35
| Facility | | $3,715.35 | $6,456.54 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $3,388.44 / $4,897.79
| Professional | | $2,137.96 | $3,388.44 | $4,897.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $6,456.54 / $6,456.54 / $15,848.93
| Professional | | $6,456.54 | $6,456.54 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $6,606.93 / $6,606.93 / $6,606.93
| Facility | | $6,606.93 | $6,606.93 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8,128.31 / $14,791.08 / $15,848.93
| Professional | | $8,128.31 | $14,791.08 | $15,848.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,388.44 / $3,981.07 / $5,888.44
| Facility | | $3,388.44 | $3,981.07 | $5,888.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $2,951.21 / $4,570.88
| Professional | | $2,137.96 | $2,951.21 | $4,570.88 |