- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Facility | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $204.17 / $302.00
| Professional | | $131.83 | $204.17 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $363.08 / $562.34
| Facility | | $245.47 | $363.08 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $331.13 / $354.81
| Professional | | $316.23 | $331.13 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $263.03
| Facility | | $162.18 | $162.18 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $162.18 / $208.93
| Professional | | $138.04 | $162.18 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $218.78 / $338.84
| Facility | | $33.88 | $218.78 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $234.42 / $257.04
| Professional | | $223.87 | $234.42 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.88 / $218.78 / $218.78
| Professional | | $21.88 | $218.78 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $363.08 / $436.52
| Facility | | $245.47 | $363.08 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $186.21
| Professional | | $177.83 | $177.83 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $257.04 / $316.23
| Professional | | $251.19 | $257.04 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $13.49 / $128.82 / $186.21
| Facility | | $13.49 | $128.82 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $158.49 / $245.47
| Professional | | $125.89 | $158.49 | $245.47 |