- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $1,380.38
| Facility | | $1,174.90 | $1,174.90 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,071.52 / $1,737.80
| Professional | | $831.76 | $1,071.52 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,174.90 / $2,089.30
| Facility | | $1,174.90 | $1,174.90 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $2,290.87 / $2,884.03
| Professional | | $1,174.90 | $2,290.87 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $2,238.72 / $2,398.83
| Professional | | $1,698.24 | $2,238.72 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $2,398.83 / $10,000.00
| Facility | | $1,288.25 | $2,398.83 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,202.26 / $3,162.28
| Professional | | $891.25 | $1,202.26 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $2,137.96 / $2,818.38
| Professional | | $2,041.74 | $2,137.96 | $2,818.38 |
- 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
- $2,137.96 / $3,162.28 / $3,162.28
| Professional | | $2,137.96 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $724.44 / $1,905.46 / $5,011.87
| Facility | | $724.44 | $1,905.46 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $933.25 / $1,778.28
| Professional | | $891.25 | $933.25 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,819.70 / $1,819.70
| Professional | | $1,445.44 | $1,819.70 | $1,819.70 |