- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,778.28 / $1,778.28
| Facility | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,778.28 / $13,803.84
| Professional | | $891.25 | $1,778.28 | $13,803.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,454.71 / $2,691.53 / $2,691.53
| Professional | | $2,454.71 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $2,089.30 / $3,090.30
| Facility | | $2,089.30 | $2,089.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $3,801.89 / $5,248.07
| Professional | | $2,089.30 | $3,801.89 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $3,090.30 / $14,454.40
| Facility | | $1,778.28 | $3,090.30 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,698.24 / $2,951.21
| Professional | | $933.25 | $1,698.24 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,019.95 / $3,019.95 / $7,413.10
| Professional | | $3,019.95 | $3,019.95 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,090.30 / $3,090.30 / $3,090.30
| Facility | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,890.45 / $6,918.31 / $7,413.10
| Professional | | $3,890.45 | $6,918.31 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,479.11 / $2,089.30 / $3,162.28
| Facility | | $1,479.11 | $2,089.30 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,380.38 / $2,187.76
| Professional | | $1,000.00 | $1,380.38 | $2,187.76 |