- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $69.18 / $186.21
| Facility | | $53.70 | $69.18 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $54.95 / $77.62
| Professional | | $53.70 | $54.95 | $77.62 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $117.49 / $309.03
| Facility | | $56.23 | $117.49 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $138.04 / $389.05
| Facility | | $64.57 | $138.04 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $57.54 / $57.54
| Professional | | $57.54 | $57.54 | $57.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $295.12
| Facility | | $295.12 | $295.12 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $67.61 / $128.82
| Facility | | $54.95 | $67.61 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $54.95 / $89.13
| Professional | | $53.70 | $54.95 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $57.54 / $57.54
| Professional | | $57.54 | $57.54 | $57.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $79.43 / $181.97
| Facility | | $57.54 | $79.43 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $57.54 / $57.54
| Professional | | $57.54 | $57.54 | $57.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $112.20 / $112.20
| Facility | | $83.18 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $56.23 / $56.23
| Professional | | $56.23 | $56.23 | $56.23 |