- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $20.89 / $37.15 / $275.42
| Facility | | $20.89 | $37.15 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.89 / $20.89 / $32.36
| Professional | | $20.89 | $20.89 | $32.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $25.12 / $58.88 / $112.20
| Facility | | $25.12 | $58.88 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.12 / $25.12 / $25.12
| Professional | | $25.12 | $25.12 | $25.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $208.93
| Facility | | $208.93 | $208.93 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $66.07 / $190.55
| Facility | | $28.18 | $66.07 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $28.18 / $28.18
| Professional | | $28.18 | $28.18 | $28.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Facility | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $20.89 / $31.62 / $229.09
| Facility | | $20.89 | $31.62 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.89 / $20.89 / $34.67
| Professional | | $20.89 | $20.89 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $21.38 / $21.38
| Professional | | $21.38 | $21.38 | $21.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $31.62 / $89.13
| Facility | | $21.38 | $31.62 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $28.18 / $28.18
| Professional | | $28.18 | $28.18 | $28.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $21.38 / $34.67
| Facility | | $21.38 | $21.38 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $21.38 / $21.38
| Professional | | $21.38 | $21.38 | $21.38 |