- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $281.84 / $575.44
| Facility | | $213.80 | $281.84 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $218.78 / $363.08
| Professional | | $213.80 | $218.78 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $223.87
| Facility | | $213.80 | $213.80 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $213.80
| Professional | | $213.80 | $213.80 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $213.80
| Facility | | $204.17 | $204.17 | $213.80 |
- 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 / $281.84 / $316.23
| Facility | | $218.78 | $281.84 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $912.01
| Professional | | $213.80 | $213.80 | $912.01 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $239.88 / $724.44
| Facility | | $204.17 | $239.88 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $257.04
| Professional | | $204.17 | $204.17 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $223.87
| Facility | | $213.80 | $213.80 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $223.87
| Professional | | $213.80 | $213.80 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $50,118.72 / $75,857.76
| Facility | | $269.15 | $50,118.72 | $75,857.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $213.80 / $346.74
| Facility | | $208.93 | $213.80 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $213.80 / $323.59
| Professional | | $194.98 | $213.80 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $251.19
| Facility | | $213.80 | $213.80 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $223.87 / $257.04
| Professional | | $213.80 | $223.87 | $257.04 |