- 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
- $831.76 / $1,000.00 / $1,584.89
| Professional | | $831.76 | $1,000.00 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,949.84 / $1,949.84 / $2,041.74
| Facility | | $1,949.84 | $1,949.84 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,071.52 / $2,238.72
| Professional | | $1,071.52 | $1,071.52 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,023.29 / $1,023.29 / $1,318.26
| Professional | | $1,023.29 | $1,023.29 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $1,513.56 / $1,513.56
| Facility | | $977.24 | $1,513.56 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,096.48 / $1,258.93
| Professional | | $1,096.48 | $1,096.48 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,445.44 / $1,949.84 / $2,691.53
| Professional | | $1,445.44 | $1,949.84 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,258.93 / $1,905.46
| Professional | | $891.25 | $1,258.93 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $1,318.26 / $2,511.89
| Facility | | $812.83 | $1,318.26 | $2,511.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,258.93 / $1,258.93
| Professional | | $1,047.13 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,584.89 / $4,073.80
| Facility | | $1,096.48 | $1,584.89 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,096.48 / $1,584.89 / $4,073.80
| Professional | | $1,096.48 | $1,584.89 | $4,073.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $676.08 / $1,318.26 / $1,949.84
| Facility | | $676.08 | $1,318.26 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $977.24 / $1,513.56
| Professional | | $870.96 | $977.24 | $1,513.56 |