- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $346.74 / $501.19
| Facility | | $208.93 | $346.74 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $245.47
| Professional | | $208.93 | $208.93 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $208.93 / $208.93
| Professional | | $177.83 | $208.93 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $213.80 / $213.80
| Facility | | $190.55 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $213.80 / $213.80
| Professional | | $169.82 | $213.80 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $316.23 / $426.58
| Facility | | $245.47 | $316.23 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $213.80
| Professional | | $213.80 | $213.80 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $213.80
| Facility | | $213.80 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $223.87 / $223.87
| Professional | | $112.20 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $245.47 / $389.05
| Professional | | $218.78 | $245.47 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $213.80 / $363.08
| Facility | | $204.17 | $213.80 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $218.78 / $234.42
| Professional | | $204.17 | $218.78 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $213.80
| Professional | | $208.93 | $208.93 | $213.80 |