- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $467.74 / $467.74
| Facility | | $467.74 | $467.74 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $467.74 / $630.96
| Professional | | $407.38 | $467.74 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $794.33 / $794.33
| Facility | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $602.56 / $602.56
| Professional | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $549.54 / $549.54
| Professional | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $549.54 / $645.65
| Professional | | $467.74 | $549.54 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $660.69 / $870.96
| Professional | | $588.84 | $660.69 | $870.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $549.54 / $794.33
| Facility | | $436.52 | $549.54 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $91.20 / $630.96
| Facility | | $48.98 | $91.20 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $91.20 / $630.96
| Professional | | $48.98 | $91.20 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $269.15 / $489.78
| Facility | | $30.90 | $269.15 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $389.05 / $691.83
| Professional | | $363.08 | $389.05 | $691.83 |