- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $63.10
| Facility | | $63.10 | $63.10 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $24.55 / $33.88 / $48.98
| Professional | | $24.55 | $33.88 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $107.15 / $114.82 / $154.88
| Professional | 50 | $107.15 | $114.82 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $34.67 / $40.74
| Professional | | $32.36 | $34.67 | $40.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $16.98 / $31.62 / $120.23
| Facility | | $16.98 | $31.62 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $29.51 / $50.12
| Professional | | $25.70 | $29.51 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $38.90 / $54.95
| Professional | | $34.67 | $38.90 | $54.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $35.48 / $35.48
| Facility | | $25.70 | $35.48 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $40.74 / $64.57
| Professional | | $29.51 | $40.74 | $64.57 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Facility | | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $295.12 / $295.12
| Professional | | $229.09 | $295.12 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $34.67 / $51.29
| Facility | | $25.70 | $34.67 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $23.99 / $33.88 / $54.95
| Professional | | $23.99 | $33.88 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $154.88
| Professional | 50 | $107.15 | $107.15 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.12 / $32.36 / $33.11
| Professional | | $25.12 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $46.77 / $46.77
| Professional | | $41.69 | $46.77 | $46.77 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $34.67 / $51.29
| Facility | | $25.70 | $34.67 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $40.74 / $66.07
| Professional | | $29.51 | $40.74 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $34.67 / $51.29
| Professional | | $25.70 | $34.67 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $36.31 / $36.31
| Professional | | $34.67 | $36.31 | $36.31 |