- 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
- $602.56 / $1,000.00 / $1,096.48
| Professional | | $602.56 | $1,000.00 | $1,096.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,513.56 / $2,754.23 / $2,754.23
| Facility | | $1,513.56 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,513.56 / $1,905.46
| Professional | | $954.99 | $1,513.56 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $467.74 / $7,585.78
| Facility | | $467.74 | $467.74 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $1,905.46 / $2,951.21
| Professional | | $398.11 | $1,905.46 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $831.76 / $1,659.59
| Facility | | $151.36 | $831.76 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $676.08 / $676.08
| Professional | | $676.08 | $676.08 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $1,000.00 / $7,943.28
| Facility | | $173.78 | $1,000.00 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $831.76 / $1,318.26
| Professional | | $575.44 | $831.76 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $89.13 / $1,148.15
| Professional | | $54.95 | $89.13 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $346.74 / $389.05
| Professional | | $173.78 | $346.74 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $2,818.38 / $8,128.31
| Facility | | $467.74 | $2,818.38 | $8,128.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $467.74 / $467.74
| Professional | | $120.23 | $467.74 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $446.68 / $977.24
| Facility | | $69.18 | $446.68 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $741.31 / $1,412.54
| Professional | | $549.54 | $741.31 | $1,412.54 |