- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $489.78 / $691.83
| Facility | | $204.17 | $489.78 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $223.87
| Professional | | $204.17 | $204.17 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $223.87 / $426.58
| Professional | | $181.97 | $223.87 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Facility | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $275.42
| Professional | | $204.17 | $204.17 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $269.15 / $416.87
| Facility | | $239.88 | $269.15 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $281.84
| Professional | | $125.89 | $125.89 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $204.17
| Facility | | $194.98 | $194.98 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $288.40
| Professional | | $204.17 | $204.17 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $117.49 / $269.15
| Professional | | $87.10 | $117.49 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $144.54 / $158.49
| Facility | | $134.90 | $144.54 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $144.54 / $269.15
| Professional | | $117.49 | $144.54 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $562.34
| Facility | | $102.33 | $102.33 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $263.03
| Professional | | $125.89 | $125.89 | $263.03 |