- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $102.33 / $16,982.44
| Facility | | $87.10 | $102.33 | $16,982.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $87.10 / $199.53
| Professional | | $85.11 | $87.10 | $199.53 |
- 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
- $87.10 / $91.20 / $302.00
| Facility | | $87.10 | $91.20 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $107.15
| Professional | | $87.10 | $87.10 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $95.50
| Professional | | $95.50 | $95.50 | $95.50 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $190.55 / $218.78
| Facility | | $107.15 | $190.55 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $93.33
| Professional | | $87.10 | $87.10 | $93.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $100.00 / $162.18
| Facility | | $85.11 | $100.00 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $91.20 / $371.54
| Professional | | $81.28 | $91.20 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $102.33 / $112.20
| Facility | | $87.10 | $102.33 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $89.13 / $100.00
| Professional | | $79.43 | $89.13 | $100.00 |