- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $181.97 / $218.78
| Facility | | $104.71 | $181.97 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $107.15 / $138.04
| Professional | | $104.71 | $107.15 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $128.82 / $275.42
| Facility | | $87.10 | $128.82 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $114.82 / $128.82
| Professional | | $104.71 | $114.82 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $158.49 / $323.59
| Facility | | $104.71 | $158.49 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $128.82
| Professional | | $104.71 | $104.71 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $104.71 / $213.80
| Facility | | $89.13 | $104.71 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $104.71 / $199.53
| Professional | | $85.11 | $104.71 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $104.71 / $125.89
| Professional | | $70.79 | $104.71 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $104.71 / $190.55
| Facility | | $100.00 | $104.71 | $190.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $109.65 / $309.03
| Facility | | $87.10 | $109.65 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $117.49
| Professional | | $107.15 | $107.15 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $128.82 / $295.12
| Facility | | $87.10 | $128.82 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $114.82 / $128.82
| Professional | | $104.71 | $114.82 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $104.71
| Facility | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $104.71 / $114.82
| Professional | | $97.72 | $104.71 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $104.71 / $138.04
| Professional | | $97.72 | $104.71 | $138.04 |