- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $169.82
| Facility | | $169.82 | $169.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $204.17 / $316.23
| Professional | | $169.82 | $204.17 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $338.84 / $478.63
| Facility | | $323.59 | $338.84 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $239.88 / $436.52
| Professional | | $169.82 | $239.88 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $25.12 / $186.21 / $316.23
| Facility | | $25.12 | $186.21 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $23.99 / $181.97 / $302.00
| Professional | | $23.99 | $181.97 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $245.47 / $257.04
| Facility | | $245.47 | $245.47 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $208.93 / $245.47
| Professional | | $177.83 | $208.93 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $245.47 / $245.47
| Facility | | $245.47 | $245.47 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $208.93 / $281.84
| Professional | | $177.83 | $208.93 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $223.87 / $363.08
| Professional | | $177.83 | $223.87 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $398.11 / $537.03
| Professional | | $323.59 | $398.11 | $537.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $14.45 / $109.65 / $234.42
| Facility | | $14.45 | $109.65 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $151.36 / $239.88
| Professional | | $104.71 | $151.36 | $239.88 |