- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $2,089.30 / $2,089.30
| Facility | | $2,089.30 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $2,089.30 / $2,089.30
| Professional | | $1,445.44 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,019.95 / $5,495.41 / $5,495.41
| Facility | | $3,019.95 | $5,495.41 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $3,019.95 / $4,265.80
| Professional | | $1,698.24 | $3,019.95 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,778.28 / $13,182.57
| Facility | | $1,778.28 | $1,778.28 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $3,981.07 / $6,309.57
| Professional | | $1,778.28 | $3,981.07 | $6,309.57 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $2,089.30 / $3,801.89
| Facility | | $870.96 | $2,089.30 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,584.89 / $1,584.89
| Professional | | $1,584.89 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $3,630.78 / $14,125.38
| Facility | | $870.96 | $3,630.78 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,584.89 / $2,951.21
| Professional | | $1,288.25 | $1,584.89 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $58.88 / $89.13
| Professional | | $50.12 | $58.88 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $3,019.95 / $5,495.41
| Professional | | $1,548.82 | $3,019.95 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $602.56 / $831.76
| Professional | | $398.11 | $602.56 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $6,456.54 / $14,125.38
| Facility | | $1,778.28 | $6,456.54 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $1,778.28 / $2,290.87
| Professional | | $1,513.56 | $1,778.28 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $1,000.00 / $2,089.30
| Facility | | $123.03 | $1,000.00 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,584.89 / $3,235.94
| Professional | | $1,047.13 | $1,584.89 | $3,235.94 |