- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $181.97 / $239.88
| Facility | | $87.10 | $181.97 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $104.71
| Professional | | $87.10 | $87.10 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $173.78 / $295.12
| Facility | | $87.10 | $173.78 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $144.54
| Professional | | $87.10 | $87.10 | $144.54 |
- 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
- $91.20 / $165.96 / $218.78
| Facility | | $91.20 | $165.96 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Professional | | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $87.10 / $102.33
| Professional | | $74.13 | $87.10 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $93.33 / $151.36
| Facility | | $87.10 | $93.33 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $87.10 / $87.10
| Professional | | $81.28 | $87.10 | $87.10 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $97.72 / $128.82
| Facility | | $83.18 | $97.72 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $97.72 / $128.82
| Professional | | $83.18 | $97.72 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $144.54 / $309.03
| Facility | | $117.49 | $144.54 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $97.72 / $128.82
| Professional | | $87.10 | $97.72 | $128.82 |