- 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 / $389.05 / $512.86
| Professional | | $389.05 | $389.05 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $724.44 / $2,041.74
| Facility | | $426.58 | $724.44 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $446.68 / $676.08
| Professional | | $389.05 | $446.68 | $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
- $389.05 / $389.05 / $524.81
| Professional | | $389.05 | $389.05 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $776.25 / $1,288.25
| Facility | | $389.05 | $776.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $389.05 / $489.78
| Professional | | $389.05 | $389.05 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $389.05 / $562.34
| Facility | | $371.54 | $389.05 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $389.05 / $549.54
| Professional | | $389.05 | $389.05 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $436.52 / $562.34
| Professional | | $389.05 | $436.52 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $436.52 / $758.58
| Professional | | $363.08 | $436.52 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $389.05 / $812.83
| Facility | | $389.05 | $389.05 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $389.05 / $436.52
| Professional | | $316.23 | $389.05 | $436.52 |