- 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
- $630.96 / $831.76 / $1,380.38
| Professional | | $630.96 | $831.76 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,096.48 / $1,096.48
| Facility | | $1,096.48 | $1,096.48 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $812.83
| Professional | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $3,090.30 / $3,715.35
| Professional | | $1,258.93 | $3,090.30 | $3,715.35 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,000.00 / $1,230.27 / $1,659.59
| Facility | | $1,000.00 | $1,230.27 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,202.26 / $1,318.26 / $1,862.09
| Professional | | $1,202.26 | $1,318.26 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,584.89 / $1,659.59
| Facility | | $1,288.25 | $1,584.89 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,412.54 / $1,659.59 / $1,659.59
| Professional | | $1,412.54 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $1,380.38 / $1,862.09
| Facility | | $831.76 | $1,380.38 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $1,380.38 / $1,737.80
| Professional | | $79.43 | $1,380.38 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $2,630.27 / $6,456.54
| Facility | | $1,380.38 | $2,630.27 | $6,456.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $1,862.09 / $1,862.09
| Professional | | $1,659.59 | $1,862.09 | $1,862.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $1,047.13 / $2,238.72
| Facility | | $660.69 | $1,047.13 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $691.83 / $1,318.26
| Professional | | $575.44 | $691.83 | $1,318.26 |