- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $16.98 / $16.98 / $16.98
| Facility | | $16.98 | $16.98 | $16.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16.98 / $16.98 / $17.38
| Professional | | $16.98 | $16.98 | $17.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $3,162.28 / $4,168.69
| Facility | | $95.50 | $3,162.28 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $58.88
| Professional | | $58.88 | $58.88 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $218.78
| Facility | | $204.17 | $204.17 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $281.84 / $281.84
| Professional | | $218.78 | $281.84 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $16.98 / $17.38 / $60.26
| Facility | | $16.98 | $17.38 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16.98 / $16.98 / $18.62
| Professional | | $16.98 | $16.98 | $18.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $51.29 / $58.88
| Professional | | $38.02 | $51.29 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $16.98 / $17.78 / $77.62
| Facility | | $16.98 | $17.78 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $79.43 / $79.43
| Professional | | $58.88 | $79.43 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $42.66 / $91.20
| Facility | | $42.66 | $42.66 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $37.15
| Professional | | $30.20 | $30.20 | $37.15 |