- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,548.82 / $1,548.82
| Facility | | $1,548.82 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,071.52 / $1,737.80
| Professional | | $870.96 | $1,071.52 | $1,737.80 |
- 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
- $891.25 / $891.25 / $891.25
| Professional | | $891.25 | $891.25 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $4,265.80 / $5,370.32
| Professional | | $1,949.84 | $4,265.80 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,949.84 / $2,630.27
| Facility | | $1,445.44 | $1,949.84 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $2,089.30 / $2,884.03
| Professional | | $1,905.46 | $2,089.30 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $2,511.89 / $2,570.40
| Facility | | $1,949.84 | $2,511.89 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $2,570.40 / $2,570.40
| Professional | | $1,949.84 | $2,570.40 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,995.26 / $2,884.03
| Facility | | $1,096.48 | $1,995.26 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $2,238.72 / $2,754.23
| Professional | | $79.43 | $2,238.72 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $4,073.80 / $10,000.00
| Facility | | $2,137.96 | $4,073.80 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,630.27 / $2,884.03 / $2,884.03
| Professional | | $2,630.27 | $2,884.03 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,202.26 / $3,162.28
| Facility | | $891.25 | $1,202.26 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $954.99 / $1,819.70
| Professional | | $758.58 | $954.99 | $1,819.70 |