- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $151.36 / $19,054.61
| Facility | | $87.10 | $151.36 | $19,054.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $87.10 / $4,365.16
| Professional | | $85.11 | $87.10 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Professional | | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $309.03 / $1,621.81
| Facility | | $128.82 | $309.03 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $104.71
| Professional | | $93.33 | $93.33 | $104.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $173.78 / $213.80
| Facility | | $120.23 | $173.78 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $104.71
| Professional | | $87.10 | $87.10 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $154.88 / $218.78
| Professional | | $85.11 | $154.88 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Professional | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $107.15 / $125.89
| Professional | | $87.10 | $107.15 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $138.04
| Facility | | $87.10 | $87.10 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $89.13 / $100.00
| Professional | | $83.18 | $89.13 | $100.00 |