- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $354.81 / $489.78
| Facility | | $223.87 | $354.81 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $223.87 / $1,445.44
| Professional | | $204.17 | $223.87 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $269.15 / $630.96
| Facility | | $204.17 | $269.15 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $234.42
| Professional | | $204.17 | $204.17 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $891.25
| Facility | | $269.15 | $269.15 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $251.19
| Professional | | $204.17 | $204.17 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $204.17 / $223.87
| Professional | | $75.86 | $204.17 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $426.58
| Facility | | $204.17 | $204.17 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $323.59 / $660.69
| Facility | | $186.21 | $323.59 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $218.78 / $234.42
| Professional | | $199.53 | $218.78 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $269.15 / $630.96
| Facility | | $204.17 | $269.15 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $234.42
| Professional | | $204.17 | $204.17 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $204.17 / $204.17
| Facility | | $81.28 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $204.17 / $204.17
| Professional | | $186.21 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $263.03
| Professional | | $204.17 | $204.17 | $263.03 |