- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $2,398.83 / $15,848.93
| Professional | | $1,096.48 | $2,398.83 | $15,848.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,311.31 / $3,630.78 / $3,630.78
| Professional | | $3,311.31 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,691.53 / $2,691.53 / $4,168.69
| Facility | | $2,691.53 | $2,691.53 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,691.53 / $4,365.16 / $6,456.54
| Professional | | $2,691.53 | $4,365.16 | $6,456.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $4,073.80 / $17,782.79
| Facility | | $2,398.83 | $4,073.80 | $17,782.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $2,238.72 / $3,715.35
| Professional | | $1,258.93 | $2,238.72 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,073.80 / $4,168.69 / $10,000.00
| Professional | | $4,073.80 | $4,168.69 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,168.69 / $4,168.69 / $4,168.69
| Facility | | $4,168.69 | $4,168.69 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,248.07 / $9,332.54 / $10,000.00
| Professional | | $5,248.07 | $9,332.54 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $2,570.40 / $3,890.45
| Facility | | $1,819.70 | $2,570.40 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,862.09 / $2,951.21
| Professional | | $1,348.96 | $1,862.09 | $2,951.21 |