- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,905.46 / $16,218.10
| Professional | | $891.25 | $1,905.46 | $16,218.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,630.27 / $2,951.21 / $2,951.21
| Professional | | $2,630.27 | $2,951.21 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $2,137.96 / $3,388.44
| Facility | | $2,137.96 | $2,137.96 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $3,801.89 / $5,370.32
| Professional | | $2,137.96 | $3,801.89 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $3,388.44 / $14,454.40
| Facility | | $1,905.46 | $3,388.44 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,819.70 / $3,019.95
| Professional | | $1,000.00 | $1,819.70 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,311.31 / $3,311.31 / $8,128.31
| Professional | | $3,311.31 | $3,311.31 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,388.44 / $3,388.44 / $3,388.44
| Facility | | $3,388.44 | $3,388.44 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,168.69 / $7,585.78 / $8,128.31
| Professional | | $4,168.69 | $7,585.78 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $2,089.30 / $3,235.94
| Facility | | $1,819.70 | $2,089.30 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,513.56 / $2,398.83
| Professional | | $1,096.48 | $1,513.56 | $2,398.83 |