- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $97.72 / $169.82
| Facility | | $57.54 | $97.72 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $97.72 / $107.15
| Professional | | $75.86 | $97.72 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $194.98 / $331.13
| Facility | | $97.72 | $194.98 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $165.96
| Professional | | $97.72 | $97.72 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $128.82 / $194.98
| Professional | | $114.82 | $128.82 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $190.55 / $239.88
| Facility | | $102.33 | $190.55 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $95.50
| Professional | | $95.50 | $95.50 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $97.72 / $117.49
| Professional | | $83.18 | $97.72 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $100.00
| Facility | | $97.72 | $97.72 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $97.72 / $144.54
| Facility | | $93.33 | $97.72 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $97.72 / $144.54
| Professional | | $93.33 | $97.72 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $102.33 / $177.83
| Facility | | $83.18 | $102.33 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $102.33 / $109.65
| Professional | | $87.10 | $102.33 | $109.65 |