- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,258.93 / $1,698.24
| Facility | | $1,258.93 | $1,258.93 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $1,096.48 / $1,659.59
| Professional | | $851.14 | $1,096.48 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,288.25 / $2,290.87
| Facility | | $1,288.25 | $1,288.25 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $2,398.83 / $3,019.95
| Professional | | $1,288.25 | $2,398.83 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $2,238.72 / $2,398.83
| Professional | | $1,778.28 | $2,238.72 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $2,511.89 / $10,000.00
| Facility | | $1,380.38 | $2,511.89 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,258.93 / $3,388.44
| Professional | | $933.25 | $1,258.93 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,238.72 / $2,290.87 / $2,884.03
| Professional | | $2,238.72 | $2,290.87 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $3,388.44 / $3,388.44
| Professional | | $2,137.96 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $2,089.30 / $5,011.87
| Facility | | $724.44 | $2,089.30 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,000.00 / $2,041.74
| Professional | | $933.25 | $1,000.00 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,995.26 / $1,995.26
| Professional | | $1,584.89 | $1,995.26 | $1,995.26 |