- 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
- $707.95 / $977.24 / $1,479.11
| Professional | | $707.95 | $977.24 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,023.29 / $1,023.29
| Facility | | $1,023.29 | $1,023.29 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $741.31 / $741.31
| Professional | | $741.31 | $741.31 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $3,630.78 / $4,365.16
| Professional | | $1,258.93 | $3,630.78 | $4,365.16 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,230.27 / $1,737.80
| Facility | | $1,000.00 | $1,230.27 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,318.26 / $1,819.70
| Professional | | $1,202.26 | $1,318.26 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,584.89 / $1,698.24
| Facility | | $1,288.25 | $1,584.89 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,479.11 / $1,621.81 / $2,137.96
| Professional | | $1,479.11 | $1,621.81 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,412.54 / $1,949.84
| Facility | | $1,000.00 | $1,412.54 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $1,412.54 / $1,698.24
| Professional | | $79.43 | $1,412.54 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,348.96 / $2,570.40 / $6,456.54
| Facility | | $1,348.96 | $2,570.40 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $1,819.70 / $1,819.70
| Professional | | $1,659.59 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $1,230.27 / $2,630.27
| Facility | | $812.83 | $1,230.27 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $812.83 / $1,548.82
| Professional | | $630.96 | $812.83 | $1,548.82 |