- 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
- $645.65 / $1,288.25 / $11,748.98
| Professional | | $645.65 | $1,288.25 | $11,748.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,949.84 / $1,949.84
| Professional | | $1,778.28 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,548.82 / $2,238.72
| Facility | | $1,548.82 | $1,548.82 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $2,754.23 / $3,890.45
| Professional | | $1,548.82 | $2,754.23 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $2,290.87 / $10,964.78
| Facility | | $1,288.25 | $2,290.87 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $1,000.00 / $2,137.96
| Professional | | $676.08 | $1,000.00 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $2,238.72 / $5,370.32
| Professional | | $2,187.76 | $2,238.72 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,238.72 / $2,238.72 / $2,238.72
| Facility | | $2,238.72 | $2,238.72 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,818.38 / $5,011.87 / $5,370.32
| Professional | | $2,818.38 | $5,011.87 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,202.26 / $2,344.23
| Facility | | $776.25 | $1,202.26 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $1,000.00 / $1,548.82
| Professional | | $724.44 | $1,000.00 | $1,548.82 |