- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $794.33 / $1,047.13
| Facility | | $380.19 | $794.33 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $457.09
| Professional | | $380.19 | $380.19 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $794.33 / $1,348.96
| Facility | | $398.11 | $794.33 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $398.11 / $660.69
| Professional | | $398.11 | $398.11 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $562.34
| Professional | | $380.19 | $380.19 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $707.95 / $1,000.00
| Facility | | $416.87 | $707.95 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $398.11 / $398.11
| Professional | | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $398.11 / $741.31
| Professional | | $338.84 | $398.11 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $416.87 / $831.76
| Facility | | $380.19 | $416.87 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $794.33
| Professional | | $380.19 | $380.19 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $524.81 / $794.33
| Facility | | $380.19 | $524.81 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $524.81 / $794.33
| Professional | | $380.19 | $524.81 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $407.38 / $870.96
| Facility | | $398.11 | $407.38 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $407.38 / $457.09
| Professional | | $380.19 | $407.38 | $457.09 |