- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $407.38 / $407.38
| Facility | | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $407.38 / $489.78
| Professional | | $223.87 | $407.38 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $398.11 / $724.44
| Facility | | $39.81 | $398.11 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $331.13 / $512.86
| Professional | | $45.71 | $331.13 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $331.13
| Facility | | $218.78 | $218.78 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $35.48 / $186.21 / $223.87
| Professional | | $35.48 | $186.21 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $141.25 / $346.74
| Facility | | $42.66 | $141.25 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $407.38 / $489.78
| Professional | | $223.87 | $407.38 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $23.99 / $234.42 / $323.59
| Professional | | $23.99 | $234.42 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $316.23 / $331.13
| Professional | | $316.23 | $316.23 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $457.09 / $457.09
| Professional | | $338.84 | $457.09 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19.05 / $131.83 / $346.74
| Facility | | $19.05 | $131.83 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $218.78 / $346.74
| Professional | | $186.21 | $218.78 | $346.74 |