- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,202.26 / $1,202.26
| Facility | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $1,202.26 / $10,000.00
| Professional | | $549.54 | $1,202.26 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $1,819.70 / $1,819.70
| Professional | | $1,659.59 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,202.26 / $2,089.30
| Facility | | $1,202.26 | $1,202.26 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $2,187.76 / $3,311.31
| Professional | | $1,202.26 | $2,187.76 | $3,311.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $2,089.30 / $9,120.11
| Facility | | $1,202.26 | $2,089.30 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $933.25 / $1,862.09
| Professional | | $630.96 | $933.25 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $2,089.30 / $5,011.87
| Professional | | $2,041.74 | $2,089.30 | $5,011.87 |
- 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
- $2,630.27 / $4,677.35 / $5,011.87
| Professional | | $2,630.27 | $4,677.35 | $5,011.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $1,023.29 / $1,995.26
| Facility | | $660.69 | $1,023.29 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $933.25 / $1,412.54
| Professional | | $676.08 | $933.25 | $1,412.54 |