- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $54.95 / $54.95
| Facility | | $54.95 | $54.95 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $54.95 / $91.20
| Professional | | $47.86 | $54.95 | $91.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $186.21
| Facility | | $112.20 | $112.20 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $104.71 / $125.89
| Professional | | $95.50 | $104.71 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $263.03 / $549.54
| Facility | | $87.10 | $263.03 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $158.49 / $213.80
| Professional | | $74.13 | $158.49 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $91.20 / $141.25
| Facility | | $54.95 | $91.20 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $107.15 / $134.90
| Professional | | $63.10 | $107.15 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $109.65 / $478.63
| Facility | | $56.23 | $109.65 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $70.79 / $125.89
| Professional | | $50.12 | $70.79 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $64.57 / $85.11
| Professional | | $50.12 | $64.57 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $128.82 / $223.87
| Professional | | $79.43 | $128.82 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $169.82 / $309.03
| Professional | | $112.20 | $169.82 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $223.87 / $512.86
| Facility | | $87.10 | $223.87 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $138.04 / $562.34
| Professional | | $74.13 | $138.04 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $74.13 / $112.20
| Facility | | $58.88 | $74.13 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $54.95 / $91.20
| Professional | | $42.66 | $54.95 | $91.20 |