- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $245.47 / $416.87
| Facility | | $208.93 | $245.47 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $213.80 / $309.03
| Professional | | $208.93 | $213.80 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $269.15
| Professional | | $213.80 | $213.80 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $309.03 / $489.78
| Professional | | $177.83 | $309.03 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $229.09 / $346.74
| Facility | | $204.17 | $229.09 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $229.09 / $912.01
| Professional | | $204.17 | $229.09 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $263.03 / $316.23
| Professional | | $245.47 | $263.03 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $269.15
| Professional | | $251.19 | $251.19 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $371.54 / $457.09
| Professional | | $229.09 | $371.54 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $245.47
| Facility | | $213.80 | $213.80 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $218.78 / $245.47
| Professional | | $208.93 | $218.78 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $229.09 / $229.09
| Facility | | $229.09 | $229.09 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $229.09 / $229.09
| Professional | | $181.97 | $229.09 | $229.09 |