- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $223.87 / $389.05
| Facility | | $194.98 | $223.87 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $199.53 / $288.40
| Professional | | $194.98 | $199.53 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $199.53 / $251.19
| Professional | | $194.98 | $199.53 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $346.74 / $549.54
| Professional | | $190.55 | $346.74 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $199.53 / $331.13
| Facility | | $190.55 | $199.53 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $208.93 / $794.33
| Professional | | $190.55 | $208.93 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $234.42 / $630.96
| Professional | | $208.93 | $234.42 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $630.96
| Professional | | $208.93 | $208.93 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $346.74 / $416.87
| Professional | | $213.80 | $346.74 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $213.80
| Facility | | $194.98 | $194.98 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $194.98 / $229.09
| Professional | | $186.21 | $194.98 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $213.80 / $213.80
| Facility | | $208.93 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $208.93 / $213.80
| Professional | | $169.82 | $208.93 | $213.80 |