- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $1,949.84 / $1,949.84
| Facility | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $1,949.84 / $13,182.57
| Professional | | $741.31 | $1,949.84 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,691.53 / $2,951.21 / $2,951.21
| Professional | | $2,691.53 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $1,698.24 / $3,388.44
| Facility | | $1,698.24 | $1,698.24 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $3,311.31 / $5,128.61
| Professional | | $1,698.24 | $3,311.31 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $3,311.31 / $11,748.98
| Facility | | $1,949.84 | $3,311.31 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,412.54 / $3,019.95
| Professional | | $954.99 | $1,412.54 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,311.31 / $3,311.31 / $8,128.31
| Professional | | $3,311.31 | $3,311.31 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,388.44 / $3,388.44 / $3,388.44
| Facility | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,168.69 / $7,585.78 / $8,128.31
| Professional | | $4,168.69 | $7,585.78 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,348.96 / $2,630.27
| Facility | | $870.96 | $1,348.96 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,412.54 / $2,290.87
| Professional | | $1,000.00 | $1,412.54 | $2,290.87 |