- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,445.44 / $1,737.80
| Professional | | $1,000.00 | $1,445.44 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $1,949.84 / $2,344.23
| Facility | | $1,949.84 | $1,949.84 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,778.28 / $1,778.28 / $1,905.46
| Professional | | $1,778.28 | $1,778.28 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $1,819.70 / $1,819.70
| Facility | | $501.19 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $1,513.56 / $1,862.09
| Professional | | $1,513.56 | $1,513.56 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,174.90 / $1,513.56
| Professional | | $1,096.48 | $1,174.90 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $1,862.09 / $3,235.94
| Facility | | $977.24 | $1,862.09 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,548.82 / $1,659.59
| Facility | | $870.96 | $1,548.82 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,174.90 / $1,659.59
| Professional | | $912.01 | $1,174.90 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $10,232.93 / $10,232.93 / $10,232.93
| Facility | | $10,232.93 | $10,232.93 | $10,232.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12,022.64 / $12,022.64 / $16,982.44
| Professional | | $12,022.64 | $12,022.64 | $16,982.44 |