- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $218.78 / $288.40
| Facility | | $104.71 | $218.78 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $114.82
| Professional | | $104.71 | $104.71 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $208.93 / $354.81
| Facility | | $104.71 | $208.93 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $177.83
| Professional | | $104.71 | $104.71 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $162.18 / $245.47
| Professional | | $144.54 | $162.18 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $199.53 / $263.03
| Facility | | $147.91 | $199.53 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $104.71
| Professional | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $104.71 / $131.83
| Professional | | $89.13 | $104.71 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $165.96
| Facility | | $104.71 | $104.71 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $117.49 / $154.88
| Facility | | $100.00 | $117.49 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $117.49 / $154.88
| Professional | | $100.00 | $117.49 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $107.15 / $213.80
| Facility | | $100.00 | $107.15 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $104.71 / $125.89
| Professional | | $100.00 | $104.71 | $125.89 |