- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $104.71 / $169.82
| Facility | | $83.18 | $104.71 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $87.10 / $104.71
| Professional | | $83.18 | $87.10 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $89.13 / $93.33
| Professional | | $75.86 | $89.13 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $154.88 / $239.88
| Professional | | $141.25 | $154.88 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $102.33 / $144.54
| Facility | | $83.18 | $102.33 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $93.33 / $398.11
| Professional | | $87.10 | $93.33 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Professional | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Professional | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $30.20
| Professional | | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $147.91
| Facility | | $104.71 | $104.71 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $89.13 / $104.71
| Professional | | $87.10 | $89.13 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $102.33
| Facility | | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $102.33 / $102.33
| Professional | | $79.43 | $102.33 | $102.33 |