- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5,754.40 / $5,754.40 / $5,754.40
| Facility | | $5,754.40 | $5,754.40 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $912.01 / $1,995.26
| Professional | | $263.03 | $912.01 | $1,995.26 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $676.08 / $676.08 / $676.08
| Professional | 50 | $676.08 | $676.08 | $676.08 |
- 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
- $389.05 / $1,174.90 / $1,288.25
| Professional | | $389.05 | $1,174.90 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $389.05 / $389.05
| Facility | | $389.05 | $389.05 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $870.96 / $1,949.84
| Professional | | $316.23 | $870.96 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $645.65 / $1,698.24
| Facility | | $416.87 | $645.65 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $645.65 / $1,698.24
| Professional | | $416.87 | $645.65 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $794.33 / $2,137.96
| Facility | | $295.12 | $794.33 | $2,137.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $660.69 / $2,290.87
| Professional | | $257.04 | $660.69 | $2,290.87 |
- 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
- $363.08 / $741.31 / $1,905.46
| Professional | | $363.08 | $741.31 | $1,905.46 |