- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $676.08 / $1,096.48
| Facility | | $389.05 | $676.08 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $398.11 / $467.74
| Professional | | $389.05 | $398.11 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $776.25 / $1,318.26
| Facility | | $389.05 | $776.25 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $389.05 / $512.86
| Professional | | $389.05 | $389.05 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $616.60 / $912.01
| Professional | | $389.05 | $616.60 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $741.31 / $977.24
| Facility | | $407.38 | $741.31 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $389.05 / $389.05
| Professional | | $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
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $131.83
| Professional | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $407.38 / $426.58
| Facility | | $177.83 | $407.38 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $407.38 / $446.68
| Professional | | $389.05 | $407.38 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $407.38 / $575.44
| Facility | | $371.54 | $407.38 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $407.38 / $575.44
| Professional | | $371.54 | $407.38 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $398.11 / $645.65
| Facility | | $158.49 | $398.11 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $389.05 / $407.38
| Professional | | $239.88 | $389.05 | $407.38 |