- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $18.20 / $18.20 / $18.20
| Facility | | $18.20 | $18.20 | $18.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12.88 / $18.20 / $125.89
| Professional | | $12.88 | $18.20 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $91.20 / $151.36
| Professional | | $38.02 | $91.20 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $169.82
| Facility | | $169.82 | $169.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $39.81 / $39.81
| Professional | | $39.81 | $39.81 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.95 / $23.99 / $51.29
| Professional | | $19.95 | $23.99 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $23.99 / $630.96 / $831.76
| Professional | | $23.99 | $630.96 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $812.83
| Facility | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $912.01 / $912.01
| Professional | | $812.83 | $912.01 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $23.99 / $26.30 / $33.11
| Professional | | $23.99 | $26.30 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $13.80 / $25.12 / $169.82
| Facility | | $13.80 | $25.12 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.95 / $23.99 / $39.81
| Professional | | $19.95 | $23.99 | $39.81 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $144.54
| Facility | | $144.54 | $144.54 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $23.99 / $120.23 / $263.03
| Professional | | $23.99 | $120.23 | $263.03 |