- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,288.25 / $1,288.25
| Facility | | $1,288.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $1,288.25 / $10,964.78
| Professional | | $602.56 | $1,288.25 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,949.84 / $1,995.26
| Professional | | $1,778.28 | $1,949.84 | $1,995.26 |
- 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 / $3,630.78
| Professional | | $1,288.25 | $2,398.83 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $2,238.72 / $10,000.00
| Facility | | $1,288.25 | $2,238.72 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $1,000.00 / $2,041.74
| Professional | | $676.08 | $1,000.00 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,238.72 / $2,238.72 / $5,495.41
| Professional | | $2,238.72 | $2,238.72 | $5,495.41 |
- 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
- $2,818.38 / $5,011.87 / $5,495.41
| Professional | | $2,818.38 | $5,011.87 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $1,122.02 / $2,187.76
| Facility | | $724.44 | $1,122.02 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $1,000.00 / $1,584.89
| Professional | | $741.31 | $1,000.00 | $1,584.89 |