- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,230.27 / $1,230.27
| Facility | | $1,230.27 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,174.90 / $1,778.28
| Professional | | $891.25 | $1,174.90 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,000.00 / $1,000.00
| Professional | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $4,570.88 / $5,495.41
| Professional | | $1,548.82 | $4,570.88 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,548.82 / $2,137.96
| Facility | | $1,230.27 | $1,548.82 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $1,659.59 / $2,290.87
| Professional | | $1,513.56 | $1,659.59 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,995.26 / $2,041.74 / $2,187.76
| Facility | | $1,995.26 | $2,041.74 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,621.81 / $1,621.81
| Professional | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $1,778.28 / $2,454.71
| Facility | | $1,174.90 | $1,778.28 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $1,778.28 / $2,137.96
| Professional | | $79.43 | $1,778.28 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,698.24 / $3,235.94 / $7,943.28
| Facility | | $1,698.24 | $3,235.94 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $2,290.87 / $2,290.87
| Professional | | $2,041.74 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,548.82 / $3,311.31
| Facility | | $794.33 | $1,548.82 | $3,311.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,023.29 / $1,949.84
| Professional | | $794.33 | $1,023.29 | $1,949.84 |