- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $660.69 / $660.69
| Facility | | $660.69 | $660.69 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $660.69 / $1,698.24
| Professional | | $331.13 | $660.69 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $851.14 / $851.14
| Professional | | $776.25 | $851.14 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $851.14 / $1,318.26
| Facility | | $851.14 | $851.14 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $1,288.25 / $2,398.83
| Professional | | $851.14 | $1,288.25 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $1,148.15 / $3,890.45
| Facility | | $660.69 | $1,148.15 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $707.95 / $1,122.02
| Professional | | $478.63 | $707.95 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,288.25 / $1,288.25 / $3,162.28
| Professional | | $1,288.25 | $1,288.25 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,737.80 / $2,884.03 / $3,162.28
| Professional | | $1,737.80 | $2,884.03 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $741.31 / $1,230.27
| Facility | | $489.78 | $741.31 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $707.95 / $1,122.02
| Professional | | $446.68 | $707.95 | $1,122.02 |