- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,778.28 / $1,778.28
| Facility | | $1,778.28 | $1,778.28 | $1,778.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $1,778.28 / $13,489.63
| Professional | | $851.14 | $1,778.28 | $13,489.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $2,691.53 / $2,691.53
| Professional | | $2,398.83 | $2,691.53 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $2,398.83 / $3,090.30
| Facility | | $2,398.83 | $2,398.83 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $3,467.37 / $5,128.61
| Professional | | $2,398.83 | $3,467.37 | $5,128.61 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $3,019.95 / $14,125.38
| Facility | | $1,778.28 | $3,019.95 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,659.59 / $2,884.03
| Professional | | $912.01 | $1,659.59 | $2,884.03 |
- 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 / $6,918.31 / $7,413.10
| Professional | | $3,801.89 | $6,918.31 | $7,413.10 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $1,862.09 / $2,818.38
| Facility | | $758.58 | $1,862.09 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,380.38 / $2,137.96
| Professional | | $1,000.00 | $1,380.38 | $2,137.96 |