- 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
- $616.60 / $1,380.38 / $9,120.11
| Professional | | $616.60 | $1,380.38 | $9,120.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $2,089.30 / $2,089.30
| Professional | | $1,905.46 | $2,089.30 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,202.26 / $2,398.83
| Facility | | $1,202.26 | $1,202.26 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $2,511.89 / $3,715.35
| Professional | | $1,202.26 | $2,511.89 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $2,344.23 / $10,000.00
| Facility | | $1,380.38 | $2,344.23 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $1,288.25 / $2,137.96
| Professional | | $707.95 | $1,288.25 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,344.23 / $2,344.23 / $5,754.40
| Professional | | $2,344.23 | $2,344.23 | $5,754.40 |
- 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
- $2,951.21 / $5,370.32 / $5,754.40
| Professional | | $2,951.21 | $5,370.32 | $5,754.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,445.44 / $2,238.72
| Facility | | $1,047.13 | $1,445.44 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $1,071.52 / $1,698.24
| Professional | | $776.25 | $1,071.52 | $1,698.24 |