- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $177.83 / $234.42
| Facility | | $89.13 | $177.83 | $234.42 |
- 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
- $83.18 / $83.18 / $141.25
| Professional | | $83.18 | $83.18 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $83.18
| Professional | | $83.18 | $83.18 | $83.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $169.82 / $223.87
| Facility | | $89.13 | $169.82 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $89.13
| Professional | | $89.13 | $89.13 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $144.54 / $144.54
| Professional | | $131.83 | $144.54 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $102.33 / $141.25
| Facility | | $85.11 | $102.33 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $104.71 / $104.71
| Professional | | $97.72 | $104.71 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $100.00 / $128.82
| Facility | | $83.18 | $100.00 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $100.00 / $128.82
| Professional | | $83.18 | $100.00 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $109.65 / $234.42
| Facility | | $89.13 | $109.65 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $93.33 / $100.00
| Professional | | $87.10 | $93.33 | $100.00 |