- 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
- $549.54 / $954.99 / $6,309.57
| Professional | | $549.54 | $954.99 | $6,309.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,318.26 / $1,445.44 / $1,445.44
| Professional | | $1,318.26 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $977.24 / $1,659.59
| Facility | | $977.24 | $977.24 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $1,737.80 / $2,570.40
| Professional | | $977.24 | $1,737.80 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $954.99 / $1,621.81 / $6,918.31
| Facility | | $954.99 | $1,621.81 | $6,918.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $891.25 / $1,445.44
| Professional | | $489.78 | $891.25 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,621.81 / $1,621.81 / $3,981.07
| Professional | | $1,621.81 | $1,621.81 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,659.59 / $1,659.59 / $1,659.59
| Facility | | $1,659.59 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,041.74 / $3,715.35 / $3,981.07
| Professional | | $2,041.74 | $3,715.35 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $870.96 / $1,023.29 / $1,548.82
| Facility | | $870.96 | $1,023.29 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $741.31 / $1,174.90
| Professional | | $537.03 | $741.31 | $1,174.90 |