- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $117.49 / $12,589.25
| Facility | | $112.20 | $117.49 | $12,589.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $141.25
| Professional | | $93.33 | $93.33 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Professional | | $93.33 | $93.33 | $93.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $102.33
| Facility | | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $102.33
| Professional | | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $117.49 / $138.04
| Facility | | $91.20 | $117.49 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $95.50 / $213.80
| Professional | | $91.20 | $95.50 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $125.89 / $194.98
| Facility | | $89.13 | $125.89 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $102.33
| Professional | | $93.33 | $93.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $104.71
| Professional | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Facility | | $93.33 | $93.33 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $93.33 / $107.15
| Professional | | $89.13 | $93.33 | $107.15 |