- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $181.97 / $239.88
| Facility | | $87.10 | $181.97 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $91.20
| Professional | | $87.10 | $87.10 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $173.78 / $295.12
| Facility | | $87.10 | $173.78 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $144.54
| Professional | | $87.10 | $87.10 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $134.90 / $204.17
| Professional | | $120.23 | $134.90 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $162.18 / $218.78
| Facility | | $120.23 | $162.18 | $218.78 |
- 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
- $74.13 / $87.10 / $109.65
| Professional | | $74.13 | $87.10 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $138.04
| Facility | | $87.10 | $87.10 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $91.20 / $128.82
| Facility | | $83.18 | $91.20 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $91.20 / $128.82
| Professional | | $83.18 | $91.20 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $141.25 / $181.97
| Facility | | $87.10 | $141.25 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $87.10 / $107.15
| Professional | | $85.11 | $87.10 | $107.15 |