- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $1,737.80 / $13,182.57
| Professional | | $741.31 | $1,737.80 | $13,182.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $2,630.27 / $2,691.53
| Professional | | $2,398.83 | $2,630.27 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $1,412.54 / $3,090.30
| Facility | | $1,412.54 | $1,412.54 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $3,467.37 / $4,677.35
| Professional | | $1,412.54 | $3,467.37 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $3,019.95 / $12,022.64
| Facility | | $1,737.80 | $3,019.95 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,513.56 / $2,754.23
| Professional | | $912.01 | $1,513.56 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,019.95 / $3,019.95 / $7,413.10
| Professional | | $3,019.95 | $3,019.95 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,090.30 / $3,090.30 / $3,090.30
| Facility | | $3,090.30 | $3,090.30 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,801.89 / $6,760.83 / $7,413.10
| Professional | | $3,801.89 | $6,760.83 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,698.24 / $2,630.27
| Facility | | $1,348.96 | $1,698.24 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,348.96 / $2,137.96
| Professional | | $1,000.00 | $1,348.96 | $2,137.96 |