- 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
- $933.25 / $1,905.46 / $14,454.40
| Professional | | $933.25 | $1,905.46 | $14,454.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,630.27 / $2,884.03 / $2,951.21
| Professional | | $2,630.27 | $2,884.03 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $1,819.70 / $3,388.44
| Facility | | $1,819.70 | $1,819.70 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,819.70 / $3,801.89 / $5,495.41
| Professional | | $1,819.70 | $3,801.89 | $5,495.41 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $3,311.31 / $15,135.61
| Facility | | $1,905.46 | $3,311.31 | $15,135.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,819.70 / $3,090.30
| Professional | | $1,000.00 | $1,819.70 | $3,090.30 |
- 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 / $7,413.10 / $8,128.31
| Professional | | $4,168.69 | $7,413.10 | $8,128.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,995.26 / $3,019.95
| Facility | | $831.76 | $1,995.26 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,479.11 / $2,344.23
| Professional | | $1,071.52 | $1,479.11 | $2,344.23 |