- 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
- $245.47 / $245.47 / $630.96
| Professional | | $245.47 | $245.47 | $630.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $263.03 / $275.42
| Facility | | $208.93 | $263.03 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $263.03 / $275.42
| Professional | | $218.78 | $263.03 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $239.88
| Facility | | $239.88 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $281.84 / $309.03
| Professional | | $245.47 | $281.84 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $263.03 / $1,174.90
| Facility | | $245.47 | $263.03 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $245.47 / $269.15
| Professional | | $97.72 | $245.47 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $281.84 / $295.12
| Professional | | $269.15 | $281.84 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $295.12
| Facility | | $295.12 | $295.12 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $234.42 / $288.40
| Facility | | $93.33 | $234.42 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $234.42 / $269.15
| Professional | | $97.72 | $234.42 | $269.15 |