- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $38.90 / $38.90
| Facility | | $38.90 | $38.90 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $38.90 / $43.65
| Professional | | $38.90 | $38.90 | $43.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $616.60 / $3,388.44
| Facility | | $223.87 | $616.60 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $120.23 / $125.89
| Facility | | $38.90 | $120.23 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $316.23 / $851.14
| Facility | | $144.54 | $316.23 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Professional | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,258.93 / $1,258.93 / $1,258.93
| Facility | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2,511.89 / $2,511.89 / $2,511.89
| Professional | | $2,511.89 | $2,511.89 | $2,511.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $41.69 / $199.53
| Facility | | $38.90 | $41.69 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $41.69 / $218.78
| Professional | | $38.90 | $41.69 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $40.74 / $45.71
| Professional | | $32.36 | $40.74 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $93.33
| Professional | | $93.33 | $93.33 | $93.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $43.65 / $245.47
| Facility | | $38.90 | $43.65 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Professional | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $446.68 / $741.31
| Facility | | $102.33 | $446.68 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $446.68
| Professional | | $125.89 | $125.89 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $125.89 / $125.89
| Professional | | $109.65 | $125.89 | $125.89 |