- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $218.78 / $295.12
| Facility | | $104.71 | $218.78 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $120.23
| Professional | | $104.71 | $104.71 | $120.23 |
- 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
- $104.71 / $104.71 / $138.04
| Professional | | $104.71 | $104.71 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $199.53 / $263.03
| Facility | | $109.65 | $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 / $125.89
| Professional | | $89.13 | $104.71 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $112.20 / $173.78
| Facility | | $104.71 | $112.20 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $104.71
| Professional | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $123.03 / $154.88
| Facility | | $100.00 | $123.03 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $123.03 / $154.88
| Professional | | $100.00 | $123.03 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $104.71 / $208.93
| Facility | | $97.72 | $104.71 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $112.20 / $117.49
| Professional | | $102.33 | $112.20 | $117.49 |