- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,174.90 / $2,398.83 / $18,197.01
| Professional | | $1,174.90 | $2,398.83 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,311.31 / $3,630.78 / $3,630.78
| Professional | | $3,311.31 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3,235.94 / $3,235.94 / $4,168.69
| Facility | | $3,235.94 | $3,235.94 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3,235.94 / $4,677.35 / $6,918.31
| Professional | | $3,235.94 | $4,677.35 | $6,918.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $4,073.80 / $19,054.61
| Facility | | $2,398.83 | $4,073.80 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $2,290.87 / $3,890.45
| Professional | | $1,230.27 | $2,290.87 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4,073.80 / $4,073.80 / $10,000.00
| Professional | | $4,073.80 | $4,073.80 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4,168.69 / $4,168.69 / $4,168.69
| Facility | | $4,168.69 | $4,168.69 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,128.61 / $9,332.54 / $10,000.00
| Professional | | $5,128.61 | $9,332.54 | $10,000.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $2,511.89 / $3,801.89
| Facility | | $1,023.29 | $2,511.89 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,862.09 / $2,951.21
| Professional | | $1,348.96 | $1,862.09 | $2,951.21 |