- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $954.99 / $954.99
| Facility | | $954.99 | $954.99 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $954.99 / $1,348.96
| Professional | | $602.56 | $954.99 | $1,348.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $1,096.48 / $1,949.84
| Facility | | $109.65 | $1,096.48 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $912.01 / $1,288.25
| Professional | | $123.03 | $912.01 | $1,288.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $741.31 / $741.31 / $776.25
| Facility | | $741.31 | $741.31 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $630.96 / $741.31
| Professional | | $85.11 | $630.96 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $524.81 / $954.99
| Facility | | $117.49 | $524.81 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $954.99 / $1,348.96
| Professional | | $602.56 | $954.99 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $87.10 / $870.96
| Professional | | $64.57 | $87.10 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $851.14 / $912.01
| Professional | | $851.14 | $851.14 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $912.01 / $1,230.27 / $1,230.27
| Professional | | $912.01 | $1,230.27 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $354.81 / $812.83
| Facility | | $40.74 | $354.81 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $478.63 / $758.58
| Professional | | $407.38 | $478.63 | $758.58 |