- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,819.70 / $3,019.95
| Professional | | $1,000.00 | $1,819.70 | $3,019.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $2,290.87 / $5,623.41
| Professional | | $2,290.87 | $2,290.87 | $5,623.41 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $263.03 / $3,388.44
| Facility | | $263.03 | $263.03 | $3,388.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $263.03 / $3,388.44
| Professional | | $263.03 | $263.03 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,862.09 / $1,862.09 / $1,862.09
| Facility | | $1,862.09 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $1,862.09 / $1,949.84
| Professional | | $269.15 | $1,862.09 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $2,398.83 / $2,398.83
| Professional | | $1,905.46 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,398.83 / $2,398.83 / $2,398.83
| Facility | | $2,398.83 | $2,398.83 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $2,290.87 / $2,398.83
| Professional | | $2,137.96 | $2,290.87 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $1,412.54 / $2,454.71
| Facility | | $177.83 | $1,412.54 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $1,995.26 / $2,951.21
| Professional | | $70.79 | $1,995.26 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,089.30 / $2,137.96 / $2,398.83
| Facility | | $2,089.30 | $2,137.96 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $2,290.87 / $2,398.83
| Professional | | $2,137.96 | $2,290.87 | $2,398.83 |