- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $275.42 / $275.42
| Facility | | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $275.42 / $331.13
| Professional | | $234.42 | $275.42 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $380.19
| Facility | | $380.19 | $380.19 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $371.54 / $380.19
| Professional | | $371.54 | $371.54 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $380.19
| Professional | | $380.19 | $380.19 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $354.81
| Facility | | $331.13 | $331.13 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $281.84 / $331.13
| Professional | | $39.81 | $281.84 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $354.81 / $436.52
| Professional | | $309.03 | $354.81 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $316.23 / $316.23
| Professional | | $316.23 | $316.23 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $234.42 / $416.87
| Facility | | $54.95 | $234.42 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $257.04 / $489.78
| Facility | | $29.51 | $257.04 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $194.98 / $467.74
| Professional | | $29.51 | $194.98 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $22.39 / $173.78 / $302.00
| Facility | | $22.39 | $173.78 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $281.84 / $407.38
| Professional | | $213.80 | $281.84 | $407.38 |