- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $1,584.89 / $1,584.89
| Facility | | $1,584.89 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $1,584.89 / $8,912.51
| Professional | | $616.60 | $1,584.89 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $2,398.83 / $2,398.83
| Professional | | $2,187.76 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,548.82 / $2,754.23
| Facility | | $1,548.82 | $1,548.82 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $2,754.23 / $4,168.69
| Professional | | $1,548.82 | $2,754.23 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,584.89 / $2,691.53 / $10,000.00
| Facility | | $1,584.89 | $2,691.53 | $10,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,258.93 / $2,041.74
| Professional | | $831.76 | $1,258.93 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,754.23 / $2,754.23 / $6,606.93
| Professional | | $2,754.23 | $2,754.23 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,754.23 / $2,754.23 / $2,754.23
| Facility | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,467.37 / $6,165.95 / $6,606.93
| Professional | | $3,467.37 | $6,165.95 | $6,606.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,479.11 / $2,187.76
| Facility | | $1,258.93 | $1,479.11 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $1,230.27 / $1,949.84
| Professional | | $851.14 | $1,230.27 | $1,949.84 |