- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $89.13 / $239.88
| Facility | | $85.11 | $89.13 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $87.10 / $91.20
| Professional | | $83.18 | $87.10 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $138.04 / $190.55
| Facility | | $104.71 | $138.04 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $100.00
| Professional | | $91.20 | $91.20 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $144.54 / $208.93
| Facility | | $104.71 | $144.54 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $104.71
| Professional | | $89.13 | $89.13 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $89.13 / $120.23
| Facility | | $83.18 | $89.13 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $147.91 / $165.96
| Facility | | $91.20 | $147.91 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $93.33 / $97.72
| Professional | | $87.10 | $93.33 | $97.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $446.68 / $446.68
| Facility | | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $467.74 / $467.74
| Professional | | $467.74 | $467.74 | $467.74 |