- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19.05 / $19.05 / $199.53
| Facility | | $19.05 | $19.05 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.05 / $30.20 / $47.86
| Professional | | $19.05 | $30.20 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.11 / $60.26 / $169.82
| Professional | | $33.11 | $60.26 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $51.29 / $56.23
| Professional | | $50.12 | $51.29 | $56.23 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19.50 / $30.20 / $61.66
| Facility | | $19.50 | $30.20 | $61.66 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19.50 / $30.20 / $141.25
| Facility | | $19.50 | $30.20 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $52.48 / $239.88
| Professional | | $28.18 | $52.48 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $54.95 / $70.79
| Professional | | $50.12 | $54.95 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $74.13 / $109.65
| Professional | | $40.74 | $74.13 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $239.88 / $239.88
| Facility | | $72.44 | $239.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $239.88 / $239.88
| Professional | | $138.04 | $239.88 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $21.88 / $389.05 / $831.76
| Facility | | $21.88 | $389.05 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $44.67 / $102.33
| Professional | | $28.84 | $44.67 | $102.33 |