- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $407.38 / $407.38
| Facility | | $407.38 | $407.38 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $398.11 / $478.63
| Professional | | $380.19 | $398.11 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $724.44
| Professional | | $380.19 | $380.19 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $169.82
| Professional | | $169.82 | $169.82 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $251.19 / $316.23
| Facility | | $177.83 | $251.19 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Professional | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $151.36 / $239.88
| Professional | | $120.23 | $151.36 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $457.09 / $645.65
| Facility | | $380.19 | $457.09 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $478.63 / $478.63
| Professional | | $109.65 | $478.63 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $138.04 / $524.81
| Facility | | $114.82 | $138.04 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $138.04 / $524.81
| Professional | | $114.82 | $138.04 | $524.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $446.68 / $478.63
| Facility | | $102.33 | $446.68 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $478.63
| Professional | | $125.89 | $125.89 | $478.63 |