- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $93.33 / $107.15
| Facility | | $87.10 | $93.33 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $109.65 / $169.82
| Professional | | $87.10 | $109.65 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $154.88
| Professional | | $154.88 | $154.88 | $154.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $208.93
| Facility | | $208.93 | $208.93 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $194.98 / $208.93
| Professional | | $154.88 | $194.98 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $389.05
| Facility | | $169.82 | $169.82 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $169.82
| Professional | | $123.03 | $123.03 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $102.33
| Facility | | $70.79 | $70.79 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $125.89 / $208.93
| Professional | | $91.20 | $125.89 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $83.18 / $104.71
| Professional | | $54.95 | $83.18 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $154.88 / $275.42
| Facility | | $91.20 | $154.88 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $102.33 / $154.88
| Professional | | $87.10 | $102.33 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $208.93
| Professional | | $83.18 | $83.18 | $208.93 |