- 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
- $1,122.02 / $2,570.40 / $16,982.44
| Professional | | $1,122.02 | $2,570.40 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,570.40 / $2,570.40 / $3,388.44
| Professional | | $2,570.40 | $2,570.40 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,548.13 / $3,890.45 / $3,890.45
| Professional | | $3,548.13 | $3,890.45 | $3,890.45 |
- 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
- $2,137.96 / $4,786.30 / $6,760.83
| Professional | | $2,137.96 | $4,786.30 | $6,760.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,570.40 / $4,365.16 / $18,197.01
| Facility | | $2,570.40 | $4,365.16 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $2,290.87 / $3,981.07
| Professional | | $1,318.26 | $2,290.87 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,365.16 / $4,365.16 / $10,715.19
| Professional | | $4,365.16 | $4,365.16 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,466.84 / $4,466.84 / $4,466.84
| Facility | | $4,466.84 | $4,466.84 | $4,466.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,495.41 / $10,000.00 / $10,715.19
| Professional | | $5,495.41 | $10,000.00 | $10,715.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $2,570.40 / $3,981.07
| Facility | | $1,949.84 | $2,570.40 | $3,981.07 |
- 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 |