- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $229.09 / $229.09
| Facility | | $229.09 | $229.09 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $229.09 / $288.40
| Professional | | $190.55 | $229.09 | $288.40 |
- 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
- $295.12 / $295.12 / $316.23
| Professional | | $295.12 | $295.12 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $316.23 / $316.23
| Professional | | $316.23 | $316.23 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $245.47 / $346.74
| Facility | | $245.47 | $245.47 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $316.23
| Professional | | $208.93 | $208.93 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $281.84 / $389.05
| Professional | | $245.47 | $281.84 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $263.03 / $338.84
| Professional | | $263.03 | $263.03 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $229.09 / $537.03
| Facility | | $141.25 | $229.09 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $26.30 / $50.12 / $389.05
| Facility | | $26.30 | $50.12 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $24.55 / $50.12 / $389.05
| Professional | | $24.55 | $50.12 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $18.20 / $151.36 / $251.19
| Facility | | $18.20 | $151.36 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $229.09 / $363.08
| Professional | | $181.97 | $229.09 | $363.08 |