- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $251.19
| Facility | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $251.19 / $323.59
| Professional | | $229.09 | $251.19 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $457.09 / $457.09
| Facility | | $457.09 | $457.09 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $346.74 / $371.54
| Professional | | $346.74 | $346.74 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $323.59
| Professional | | $323.59 | $323.59 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $229.09 / $331.13
| Facility | | $229.09 | $229.09 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $331.13
| Professional | | $194.98 | $194.98 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $380.19 / $537.03
| Professional | | $338.84 | $380.19 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $380.19
| Professional | | $295.12 | $295.12 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $251.19 / $512.86
| Facility | | $158.49 | $251.19 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $234.42 / $457.09
| Facility | | $28.84 | $234.42 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $54.95 / $436.52
| Professional | | $28.84 | $54.95 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19.95 / $169.82 / $302.00
| Facility | | $19.95 | $169.82 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $245.47 / $380.19
| Professional | | $213.80 | $245.47 | $380.19 |