- 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
- Facility
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $724.44 / $1,995.26
| Facility | | $426.58 | $724.44 | $1,995.26 |
- 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 / $501.19
| Professional | | $389.05 | $389.05 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $389.05 / $1,000.00
| Facility | | $371.54 | $389.05 | $1,000.00 |
- 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 / $426.58 / $562.34
| Professional | | $389.05 | $426.58 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $436.52 / $741.31
| Professional | | $371.54 | $436.52 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $389.05 / $776.25
| Facility | | $389.05 | $389.05 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $389.05 / $436.52
| Professional | | $363.08 | $389.05 | $436.52 |