- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $134.90 / $12,882.50
| Facility | | $93.33 | $134.90 | $12,882.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $158.49
| Professional | | $93.33 | $93.33 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $162.18
| Professional | | $93.33 | $93.33 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $102.33 / $102.33
| Facility | | $75.86 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $112.20 / $114.82
| Professional | | $109.65 | $112.20 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $107.15 / $138.04
| Professional | | $93.33 | $107.15 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $117.49 / $177.83
| Facility | | $85.11 | $117.49 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $102.33 / $389.05
| Professional | | $91.20 | $102.33 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $134.90 / $138.04
| Professional | | $107.15 | $134.90 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $131.83 / $229.09
| Professional | | $109.65 | $131.83 | $229.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $93.33 / $177.83
| Facility | | $81.28 | $93.33 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $93.33 / $112.20
| Professional | | $89.13 | $93.33 | $112.20 |