- 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
- $245.47 / $309.03 / $346.74
| Professional | | $245.47 | $309.03 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $512.86 / $512.86
| Facility | | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $371.54 / $371.54
| Professional | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $346.74 / $346.74
| Professional | | $346.74 | $346.74 | $346.74 |
- 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
- $263.03 / $263.03 / $354.81
| Professional | | $263.03 | $263.03 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $436.52 / $562.34
| Professional | | $380.19 | $436.52 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $281.84
| Professional | | $251.19 | $251.19 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $275.42 / $512.86
| Facility | | $138.04 | $275.42 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $31.62 / $60.26 / $416.87
| Facility | | $31.62 | $60.26 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $31.62 / $60.26 / $416.87
| Professional | | $31.62 | $60.26 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $16.98 / $144.54 / $281.84
| Facility | | $16.98 | $144.54 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $251.19 / $398.11
| Professional | | $208.93 | $251.19 | $398.11 |