- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $223.87
| Facility | | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $223.87 / $302.00
| Professional | | $128.82 | $223.87 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $371.54 / $489.78
| Facility | | $245.47 | $371.54 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $323.59 / $346.74
| Professional | | $302.00 | $323.59 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $239.88
| Facility | | $165.96 | $165.96 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $165.96 / $199.53
| Professional | | $141.25 | $165.96 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $31.62 / $213.80 / $316.23
| Facility | | $31.62 | $213.80 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $239.88 / $263.03
| Professional | | $223.87 | $239.88 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $213.80 / $213.80
| Professional | | $21.38 | $213.80 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $371.54 / $436.52
| Facility | | $245.47 | $371.54 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $181.97 / $190.55
| Professional | | $181.97 | $181.97 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $263.03 / $309.03
| Professional | | $257.04 | $263.03 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $12.88 / $128.82 / $181.97
| Facility | | $12.88 | $128.82 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $147.91 / $229.09
| Professional | | $128.82 | $147.91 | $229.09 |