- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $154.88 / $457.09
| Facility | | $25.70 | $154.88 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $25.70 / $42.66
| Professional | | $25.70 | $25.70 | $42.66 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $26.30 / $26.92
| Facility | | $25.70 | $26.30 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.30 / $26.30 / $26.30
| Professional | | $26.30 | $26.30 | $26.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.30 / $28.18 / $33.11
| Professional | | $26.30 | $28.18 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $47.86 / $165.96
| Facility | | $28.18 | $47.86 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $31.62 / $575.44
| Professional | | $28.18 | $31.62 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $42.66 / $60.26
| Professional | | $30.90 | $42.66 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $69.18 / $69.18
| Professional | | $69.18 | $69.18 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $28.84 / $190.55
| Professional | | $28.84 | $28.84 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.30 / $28.84 / $60.26
| Professional | | $26.30 | $28.84 | $60.26 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $22.39 / $22.39 / $28.84
| Facility | | $22.39 | $22.39 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22.39 / $28.84 / $28.84
| Professional | | $22.39 | $28.84 | $28.84 |