- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $141.25 / $251.19
| Facility | | $28.18 | $141.25 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.89 / $32.36 / $77.62
| Professional | | $20.89 | $32.36 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.95 / $19.95 / $19.95
| Professional | | $19.95 | $19.95 | $19.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $36.31 / $85.11 / $144.54
| Facility | | $36.31 | $85.11 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.12 / $42.66 / $77.62
| Professional | | $25.12 | $42.66 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $42.66 / $42.66
| Professional | | $42.66 | $42.66 | $42.66 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $26.92 / $39.81 / $64.57
| Facility | | $26.92 | $39.81 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $54.95 / $109.65
| Professional | | $34.67 | $54.95 | $109.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $10.72 / $35.48 / $81.28
| Facility | | $10.72 | $35.48 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $34.67 / $64.57
| Professional | | $25.70 | $34.67 | $64.57 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $363.08
| Facility | | $204.17 | $204.17 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $263.03
| Professional | | $204.17 | $204.17 | $263.03 |