- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $181.97 / $239.88
| Facility | | $131.83 | $181.97 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $123.03
| Professional | | $87.10 | $87.10 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $104.71 / $263.03
| Facility | | $91.20 | $104.71 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $218.78
| Professional | | $87.10 | $87.10 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $100.00 / $162.18
| Facility | | $87.10 | $100.00 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $112.20 / $239.88
| Professional | | $87.10 | $112.20 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $147.91 / $199.53
| Facility | | $89.13 | $147.91 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Professional | | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $95.50 / $190.55
| Professional | | $77.62 | $95.50 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $436.52 / $436.52
| Facility | | $436.52 | $436.52 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $134.90 / $218.78
| Facility | | $87.10 | $134.90 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $91.20
| Professional | | $87.10 | $87.10 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $95.50 / $147.91
| Professional | | $69.18 | $95.50 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $257.04 / $257.04
| Facility | | $87.10 | $257.04 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $213.80
| Professional | | $87.10 | $87.10 | $213.80 |