- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $97.72 / $151.36
| Facility | | $53.70 | $97.72 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $97.72 / $97.72
| Professional | | $83.18 | $97.72 | $97.72 |
- 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
- $51.29 / $97.72 / $147.91
| Facility | | $51.29 | $97.72 | $147.91 |
- 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 / $117.49
| Professional | | $87.10 | $102.33 | $117.49 |