- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $724.44 / $1,047.13
| Facility | | $346.74 | $724.44 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $346.74 / $380.19
| Professional | | $346.74 | $346.74 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $426.58 / $724.44
| Facility | | $213.80 | $426.58 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $363.08
| Professional | | $213.80 | $213.80 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $302.00 / $457.09
| Professional | | $263.03 | $302.00 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $407.38 / $537.03
| Facility | | $302.00 | $407.38 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $213.80
| Professional | | $213.80 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $346.74 / $446.68
| Professional | | $181.97 | $346.74 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.63 / $2.63 / $2.63
| Professional | | $2.63 | $2.63 | $2.63 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4.07 / $346.74 / $346.74
| Facility | | $4.07 | $346.74 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $257.04 / $575.44
| Facility | | $204.17 | $257.04 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $257.04 / $575.44
| Professional | | $204.17 | $257.04 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $281.84 / $616.60
| Facility | | $213.80 | $281.84 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $346.74 / $363.08
| Professional | | $281.84 | $346.74 | $363.08 |