- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $1,949.84 / $1,949.84
| Facility | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,949.84 / $16,595.87
| Professional | | $912.01 | $1,949.84 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,691.53 / $2,951.21 / $2,951.21
| Professional | | $2,691.53 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $2,041.74 / $3,388.44
| Facility | | $2,041.74 | $2,041.74 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $3,388.44 / $5,495.41
| Professional | | $2,041.74 | $3,388.44 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $3,388.44 / $15,135.61
| Facility | | $1,949.84 | $3,388.44 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,862.09 / $3,019.95
| Professional | | $1,000.00 | $1,862.09 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,311.31 / $3,311.31 / $8,128.31
| Professional | | $3,311.31 | $3,311.31 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,388.44 / $3,388.44 / $3,388.44
| Facility | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,168.69 / $7,585.78 / $8,128.31
| Professional | | $4,168.69 | $7,585.78 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,862.09 / $2,137.96 / $3,311.31
| Facility | | $1,862.09 | $2,137.96 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,513.56 / $2,398.83
| Professional | | $1,096.48 | $1,513.56 | $2,398.83 |