- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $162.18 / $239.88
| Facility | | $87.10 | $162.18 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $114.82
| Professional | | $87.10 | $87.10 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $162.18 / $446.68
| Facility | | $93.33 | $162.18 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $100.00 / $151.36
| Professional | | $87.10 | $100.00 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $85.11
| Facility | | $85.11 | $85.11 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $114.82
| Professional | | $85.11 | $85.11 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $173.78 / $288.40
| Facility | | $87.10 | $173.78 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $112.20
| Professional | | $87.10 | $87.10 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $87.10 / $177.83
| Facility | | $81.28 | $87.10 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $120.23
| Professional | | $87.10 | $87.10 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $95.50 / $123.03
| Professional | | $85.11 | $95.50 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $100.00 / $165.96
| Professional | | $83.18 | $100.00 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $251.19 / $251.19
| Facility | | $125.89 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $97.72 / $125.89
| Professional | | $87.10 | $97.72 | $125.89 |