- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $446.68 / $588.84
| Facility | | $208.93 | $446.68 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $245.47
| Professional | | $208.93 | $208.93 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $426.58 / $724.44
| Facility | | $213.80 | $426.58 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $354.81
| Professional | | $213.80 | $213.80 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $281.84
| Professional | | $208.93 | $208.93 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $398.11 / $537.03
| Facility | | $223.87 | $398.11 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $213.80
| Professional | | $213.80 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $213.80 / $251.19
| Professional | | $181.97 | $213.80 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $223.87 / $354.81
| Facility | | $208.93 | $223.87 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $223.87
| Professional | | $208.93 | $208.93 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $239.88 / $309.03
| Facility | | $199.53 | $239.88 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $239.88 / $309.03
| Professional | | $199.53 | $239.88 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $213.80 / $436.52
| Facility | | $204.17 | $213.80 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $223.87 / $239.88
| Professional | | $208.93 | $223.87 | $239.88 |