- 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
- $588.84 / $1,230.27 / $10,715.19
| Professional | | $588.84 | $1,230.27 | $10,715.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $1,862.09 / $1,862.09
| Professional | | $1,659.59 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $1,412.54 / $2,137.96
| Facility | | $1,412.54 | $1,412.54 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $2,290.87 / $3,548.13
| Professional | | $1,412.54 | $2,290.87 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $2,137.96 / $10,000.00
| Facility | | $1,230.27 | $2,137.96 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $1,174.90 / $1,949.84
| Professional | | $630.96 | $1,174.90 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $2,089.30 / $5,128.61
| Professional | | $2,089.30 | $2,089.30 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $2,137.96 / $2,137.96
| Facility | | $2,137.96 | $2,137.96 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,630.27 / $4,786.30 / $5,128.61
| Professional | | $2,630.27 | $4,786.30 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,380.38 / $2,137.96
| Facility | | $1,202.26 | $1,380.38 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $954.99 / $1,513.56
| Professional | | $691.83 | $954.99 | $1,513.56 |