- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $426.58 / $2,754.23
| Facility | | $204.17 | $426.58 | $2,754.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $208.93 / $223.87
| Professional | | $204.17 | $208.93 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $407.38 / $691.83
| Facility | | $204.17 | $407.38 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $269.15
| Professional | | $204.17 | $204.17 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $316.23 / $478.63
| Professional | | $204.17 | $316.23 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $380.19 / $512.86
| Facility | | $213.80 | $380.19 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Professional | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $204.17 / $245.47
| Professional | | $154.88 | $204.17 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $194.98
| Professional | | $194.98 | $194.98 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $213.80 / $234.42
| Facility | | $204.17 | $213.80 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $213.80 / $234.42
| Professional | | $204.17 | $213.80 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $199.53 / $302.00
| Facility | | $194.98 | $199.53 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $199.53 / $302.00
| Professional | | $194.98 | $199.53 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $204.17 / $338.84
| Facility | | $81.28 | $204.17 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $204.17 / $213.80
| Professional | | $125.89 | $204.17 | $213.80 |