- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $831.76 / $1,348.96
| Facility | | $389.05 | $831.76 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $389.05 / $575.44
| Professional | | $389.05 | $389.05 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $389.05 / $676.08
| Professional | | $331.13 | $389.05 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $389.05 / $389.05
| Facility | | $389.05 | $389.05 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $389.05 / $467.74
| Professional | | $295.12 | $389.05 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $588.84 / $776.25
| Facility | | $398.11 | $588.84 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $389.05 / $398.11
| Professional | | $389.05 | $389.05 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $389.05 / $389.05
| Facility | | $104.71 | $389.05 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $398.11 / $398.11
| Professional | | $389.05 | $398.11 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $389.05
| Professional | | $295.12 | $295.12 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $389.05 / $478.63
| Facility | | $39.81 | $389.05 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $389.05 / $398.11
| Professional | | $154.88 | $389.05 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $389.05 / $398.11
| Professional | | $389.05 | $389.05 | $398.11 |