- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $2,041.74 / $4,168.69
| Facility | | $2,041.74 | $2,041.74 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $2,041.74 / $3,801.89
| Professional | | $1,584.89 | $2,041.74 | $3,801.89 |
- 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
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,897.79 / $7,943.28 / $28,183.83
| Facility | | $4,897.79 | $7,943.28 | $28,183.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,162.28 / $3,162.28 / $3,162.28
| Professional | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $2,137.96 / $4,466.84
| Facility | | $2,137.96 | $2,137.96 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,584.89 / $4,365.16
| Professional | | $1,584.89 | $1,584.89 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,467.37 / $4,365.16 / $5,495.41
| Professional | | $3,467.37 | $4,365.16 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,370.32 / $5,370.32 / $5,370.32
| Professional | | $5,370.32 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,344.23 / $2,344.23 / $3,311.31
| Professional | | $2,344.23 | $2,344.23 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $3,388.44 / $5,623.41
| Facility | | $2,290.87 | $3,388.44 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $2,041.74 / $3,388.44
| Professional | | $1,548.82 | $2,041.74 | $3,388.44 |