- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $691.83 / $1,621.81 / $2,290.87
| Facility | | $691.83 | $1,621.81 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,174.90 / $1,621.81
| Professional | | $831.76 | $1,174.90 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $2,041.74 / $4,073.80
| Facility | | $2,041.74 | $2,041.74 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,230.27 / $1,230.27 / $3,467.37
| Professional | | $1,230.27 | $1,230.27 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,659.59 / $1,659.59
| Facility | | $1,548.82 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $1,659.59 / $1,659.59
| Professional | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,548.82 / $1,548.82 / $53,703.18
| Facility | | $1,548.82 | $1,548.82 | $53,703.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $2,818.38
| Professional | | $1,122.02 | $1,122.02 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $3,388.44 / $7,943.28
| Facility | | $2,041.74 | $3,388.44 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $2,041.74 / $3,890.45
| Professional | | $1,288.25 | $2,041.74 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,000.00 / $1,047.13
| Facility | | $1,000.00 | $1,000.00 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,202.26 / $1,288.25
| Professional | | $1,000.00 | $1,202.26 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,137.96 / $50,118.72 / $75,857.76
| Facility | | $2,137.96 | $50,118.72 | $75,857.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $1,949.84 / $1,949.84
| Professional | | $1,348.96 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,174.90 / $5,754.40
| Facility | | $831.76 | $1,174.90 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $758.58 / $1,348.96 / $3,388.44
| Professional | | $758.58 | $1,348.96 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,202.26 / $1,202.26
| Facility | | $1,000.00 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,202.26 / $1,288.25
| Professional | | $1,000.00 | $1,202.26 | $1,288.25 |