- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $239.88 / $12,022.64
| Facility | | $93.33 | $239.88 | $12,022.64 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $125.89
| Professional | | $93.33 | $93.33 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $186.21 / $316.23
| Facility | | $93.33 | $186.21 | $316.23 |
- 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 / $125.89
| Professional | | $93.33 | $93.33 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $177.83 / $234.42
| Facility | | $97.72 | $177.83 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Professional | | $93.33 | $93.33 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $93.33 / $112.20
| Professional | | $79.43 | $93.33 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $100.00 / $154.88
| Facility | | $93.33 | $100.00 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $97.72
| Professional | | $93.33 | $93.33 | $97.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $102.33 / $138.04
| Facility | | $89.13 | $102.33 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $102.33 / $138.04
| Professional | | $89.13 | $102.33 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $93.33 / $190.55
| Facility | | $89.13 | $93.33 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $100.00 / $104.71
| Professional | | $93.33 | $100.00 | $104.71 |