- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $257.04 / $380.19
| Facility | | $239.88 | $257.04 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $295.12 / $380.19
| Professional | | $223.87 | $295.12 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.00 / $10.00 / $10.00
| Professional | | $10.00 | $10.00 | $10.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $97.72 / $208.93
| Facility | | $41.69 | $97.72 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $40.74 / $40.74
| Professional | | $40.74 | $40.74 | $40.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $45.71 / $45.71
| Facility | | $45.71 | $45.71 | $45.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $416.87 / $416.87
| Facility | | $416.87 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $812.83 / $812.83 / $812.83
| Professional | | $812.83 | $812.83 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5,248.07 / $5,248.07 / $7,585.78
| Facility | | $5,248.07 | $5,248.07 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $54.95 / $54.95
| Professional | | $54.95 | $54.95 | $54.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $93.33 / $416.87
| Facility | | $44.67 | $93.33 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $288.40 / $380.19
| Professional | | $223.87 | $288.40 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $97.72 / $416.87
| Facility | | $47.86 | $97.72 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $812.83 / $812.83
| Professional | | $52.48 | $812.83 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $23.44 / $39.81 / $1,047.13
| Facility | | $23.44 | $39.81 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.50 / $28.18 / $51.29
| Professional | | $19.50 | $28.18 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $302.00 / $371.54
| Professional | | $51.29 | $302.00 | $371.54 |