- 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
- $457.09 / $602.56 / $954.99
| Professional | | $457.09 | $602.56 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $831.76 / $831.76 / $891.25
| Professional | | $831.76 | $831.76 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $602.56 / $602.56
| Facility | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $446.68 / $645.65
| Professional | | $446.68 | $446.68 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $549.54 / $724.44
| Professional | | $512.86 | $549.54 | $724.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $954.99 / $1,621.81
| Facility | | $363.08 | $954.99 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $1,071.52 / $1,122.02
| Professional | | $0.60 | $1,071.52 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $489.78 / $891.25
| Facility | | $331.13 | $489.78 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $512.86 / $776.25
| Professional | | $323.59 | $512.86 | $776.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5,128.61 / $5,128.61 / $5,128.61
| Facility | | $5,128.61 | $5,128.61 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,623.41 / $5,623.41 / $7,943.28
| Professional | | $5,623.41 | $5,623.41 | $7,943.28 |