- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5.89 / $295.12 / $398.11
| Facility | | $5.89 | $295.12 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $295.12
| Professional | | $295.12 | $295.12 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $371.54 / $537.03
| Facility | | $316.23 | $371.54 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $346.74 / $707.95
| Professional | | $295.12 | $346.74 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $39.81 / $39.81
| Professional | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $645.65 / $812.83
| Facility | | $323.59 | $645.65 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $323.59
| Professional | | $323.59 | $323.59 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $512.86 / $1,023.29
| Professional | | $380.19 | $512.86 | $1,023.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,047.13 / $1,047.13 / $1,047.13
| Facility | | $1,047.13 | $1,047.13 | $1,047.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $426.58 / $812.83
| Facility | | $323.59 | $426.58 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $323.59
| Professional | | $323.59 | $323.59 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $295.12 / $380.19
| Professional | | $223.87 | $295.12 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $309.03
| Facility | | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $346.74 / $758.58
| Professional | | $323.59 | $346.74 | $758.58 |