- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $186.21 / $34,673.69
| Facility | | $87.10 | $186.21 | $34,673.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $87.10 / $138.04
| Professional | | $85.11 | $87.10 | $138.04 |
- 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
- $93.33 / $138.04 / $309.03
| Facility | | $93.33 | $138.04 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $97.72 / $147.91
| Professional | | $87.10 | $97.72 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Facility | | $204.17 | $204.17 | $204.17 |
- 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
- $85.11 / $85.11 / $128.82
| Facility | | $85.11 | $85.11 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $199.53
| Professional | | $85.11 | $85.11 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $169.82 / $281.84
| Facility | | $87.10 | $169.82 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $109.65
| Professional | | $87.10 | $87.10 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $123.03 / $275.42
| Facility | | $81.28 | $123.03 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $123.03
| Professional | | $87.10 | $87.10 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $95.50 / $123.03
| Professional | | $85.11 | $95.50 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $100.00 / $165.96
| Professional | | $81.28 | $100.00 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $181.97
| Facility | | $87.10 | $87.10 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $87.10 / $100.00
| Professional | | $81.28 | $87.10 | $100.00 |