- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $707.95 / $707.95
| Facility | | $707.95 | $707.95 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $707.95 / $831.76
| Professional | | $707.95 | $707.95 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $245.47 / $302.00
| Facility | | $190.55 | $245.47 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $630.96 / $1,047.13 / $1,258.93
| Professional | | $630.96 | $1,047.13 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $1,023.29 / $1,949.84
| Professional | | $275.42 | $1,023.29 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $1,258.93 / $2,238.72
| Facility | | $933.25 | $1,258.93 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $933.25 / $1,698.24
| Professional | | $933.25 | $933.25 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,071.52 / $1,174.90 / $1,659.59
| Professional | | $1,071.52 | $1,174.90 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $245.47 / $302.00
| Facility | | $204.17 | $245.47 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,905.46 / $1,905.46 / $1,905.46
| Professional | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.98 / $977.24 / $1,621.81
| Facility | | $0.98 | $977.24 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $977.24
| Professional | | $125.89 | $125.89 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $707.95 / $707.95
| Facility | | $707.95 | $707.95 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $707.95 / $707.95
| Professional | | $707.95 | $707.95 | $707.95 |