- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19.95 / $29.51 / $389.05
| Facility | | $19.95 | $29.51 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.95 / $28.84 / $37.15
| Professional | | $19.95 | $28.84 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.89 / $20.89 / $20.89
| Professional | | $20.89 | $20.89 | $20.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $38.02 / $38.02
| Facility | | $30.20 | $38.02 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $38.02 / $38.02
| Professional | | $30.20 | $38.02 | $38.02 |
- 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
- $25.70 / $25.70 / $25.70
| Professional | | $25.70 | $25.70 | $25.70 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $67.61
| Facility | | $67.61 | $67.61 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22.91 / $22.91 / $35.48
| Professional | | $22.91 | $22.91 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Professional | | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $38.02 / $46.77
| Facility | | $30.20 | $38.02 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.50 / $36.31 / $58.88
| Professional | | $19.50 | $36.31 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $123.03 / $123.03
| Professional | | $38.02 | $123.03 | $123.03 |