- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $302.00 / $302.00
| Facility | | $302.00 | $302.00 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $302.00 / $416.87
| Professional | | $194.98 | $302.00 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $467.74 / $602.56
| Facility | | $338.84 | $467.74 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $398.11 / $416.87
| Professional | | $380.19 | $398.11 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $239.88 / $251.19
| Facility | | $213.80 | $239.88 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $239.88 / $275.42
| Professional | | $204.17 | $239.88 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $199.53 / $398.11
| Facility | | $107.15 | $199.53 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $363.08 / $380.19
| Professional | | $354.81 | $363.08 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.92 / $263.03 / $269.15
| Professional | | $26.92 | $263.03 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $549.54 / $602.56
| Facility | | $363.08 | $549.54 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $263.03 / $275.42
| Professional | | $263.03 | $263.03 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $380.19 / $398.11
| Professional | | $281.84 | $380.19 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $13.18 / $131.83 / $257.04
| Facility | | $13.18 | $131.83 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $165.96 / $263.03
| Professional | | $151.36 | $165.96 | $263.03 |