- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $426.58 / $6,165.95
| Facility | | $204.17 | $426.58 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $354.81
| Professional | | $204.17 | $204.17 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Professional | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $331.13 / $724.44
| Facility | | $218.78 | $331.13 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $213.80 / $354.81
| Professional | | $204.17 | $213.80 | $354.81 |
- 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
- $213.80 / $407.38 / $676.08
| Facility | | $213.80 | $407.38 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $208.93
| Professional | | $204.17 | $204.17 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $199.53 / $204.17
| Facility | | $194.98 | $199.53 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $204.17 / $234.42
| Professional | | $199.53 | $204.17 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $223.87 / $295.12
| Professional | | $204.17 | $223.87 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $251.19 / $416.87
| Professional | | $190.55 | $251.19 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $204.17 / $436.52
| Facility | | $81.28 | $204.17 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $204.17 / $208.93
| Professional | | $81.28 | $204.17 | $208.93 |