- 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
- $1,000.00 / $1,698.24 / $1,905.46
| Professional | | $1,000.00 | $1,698.24 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,778.28 / $1,949.84
| Professional | | $1,778.28 | $1,778.28 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,949.84 / $1,949.84
| Facility | | $1,023.29 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,445.44 / $2,041.74
| Professional | | $1,445.44 | $1,445.44 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,412.54 / $1,548.82
| Professional | | $1,318.26 | $1,412.54 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,949.84 / $3,388.44
| Facility | | $1,000.00 | $1,949.84 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,737.80 / $1,905.46
| Facility | | $1,096.48 | $1,737.80 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,148.15 / $1,778.28
| Professional | | $954.99 | $1,148.15 | $1,778.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $12,302.69 / $12,302.69 / $12,302.69
| Facility | | $12,302.69 | $12,302.69 | $12,302.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15,135.61 / $15,135.61 / $22,908.68
| Professional | | $15,135.61 | $15,135.61 | $22,908.68 |