- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $114.82 / $616.60
| Facility | | $54.95 | $114.82 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $56.23 / $57.54
| Professional | | $54.95 | $56.23 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $54.95 / $72.44
| Professional | | $54.95 | $54.95 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $85.11 / $128.82
| Professional | | $54.95 | $85.11 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $104.71 / $138.04
| Facility | | $57.54 | $104.71 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $54.95 / $54.95
| Professional | | $54.95 | $54.95 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $54.95 / $66.07
| Professional | | $41.69 | $54.95 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.88 / $21.88 / $21.88
| Professional | | $21.88 | $21.88 | $21.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $57.54 / $60.26
| Facility | | $25.70 | $57.54 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $57.54 / $63.10
| Professional | | $54.95 | $57.54 | $63.10 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $57.54 / $81.28
| Facility | | $52.48 | $57.54 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $57.54 / $81.28
| Professional | | $52.48 | $57.54 | $81.28 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $50.12 / $89.13
| Facility | | $21.38 | $50.12 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $54.95 / $56.23
| Professional | | $33.88 | $54.95 | $56.23 |