- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3.16 / $67.61 / $251.19
| Facility | | $3.16 | $67.61 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $57.54 / $72.44
| Professional | | $43.65 | $57.54 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $57.54 / $75.86
| Professional | | $29.51 | $57.54 | $75.86 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $85.11 / $134.90
| Facility | | $64.57 | $85.11 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $57.54 / $72.44
| Professional | | $57.54 | $57.54 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4.79 / $4.79 / $4.79
| Professional | | $4.79 | $4.79 | $4.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4.47 / $57.54 / $79.43
| Facility | | $4.47 | $57.54 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.00 / $2.00 / $72.44
| Professional | | $2.00 | $2.00 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $91.20 / $91.20
| Professional | | $0.60 | $91.20 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $83.18 / $93.33
| Facility | | $61.66 | $83.18 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $57.54 / $58.88
| Professional | | $50.12 | $57.54 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $257.04 / $257.04
| Facility | | $257.04 | $257.04 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $309.03 / $309.03
| Professional | | $309.03 | $309.03 | $309.03 |