- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $239.88 / $645.65
| Facility | | $104.71 | $239.88 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $109.65 / $371.54
| Professional | | $104.71 | $109.65 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $208.93 / $363.08
| Facility | | $104.71 | $208.93 | $363.08 |
- 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
- $154.88 / $177.83 / $269.15
| Professional | | $154.88 | $177.83 | $269.15 |
- 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 / $436.52
| Professional | | $89.13 | $104.71 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $154.88
| Professional | | $154.88 | $154.88 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $263.03 / $371.54
| Facility | | $89.13 | $263.03 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $154.88 / $363.08
| Facility | | $100.00 | $154.88 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $154.88 / $363.08
| Professional | | $100.00 | $154.88 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $158.49 / $338.84
| Facility | | $104.71 | $158.49 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $104.71 / $162.18
| Professional | | $102.33 | $104.71 | $162.18 |