- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $851.14 / $5,754.40
| Facility | | $851.14 | $851.14 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $524.81 / $1,584.89
| Professional | | $173.78 | $524.81 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $79.43 / $870.96 / $1,288.25
| Professional | 50 | $79.43 | $870.96 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64,565.42 / $77,624.71 / $95,499.26
| Facility | | $64,565.42 | $77,624.71 | $95,499.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $1,288.25
| Professional | | $269.15 | $269.15 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $269.15
| Facility | | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $269.15 / $1,288.25
| Professional | | $208.93 | $269.15 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $363.08 / $1,548.82
| Facility | | $288.40 | $363.08 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $363.08 / $1,548.82
| Professional | | $288.40 | $363.08 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $1,023.29 / $1,513.56
| Facility | | $263.03 | $1,023.29 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $269.15 / $1,380.38
| Professional | | $79.43 | $269.15 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $707.95 / $1,737.80
| Professional | | $269.15 | $707.95 | $1,737.80 |