- 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
- $54.95 / $56.23 / $58.88
| Professional | | $54.95 | $56.23 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $66.07 / $89.13
| Professional | | $50.12 | $66.07 | $89.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $91.20 / $177.83
| Facility | | $77.62 | $91.20 | $177.83 |
- 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
- $54.95 / $58.88 / $85.11
| Facility | | $54.95 | $58.88 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $69.18 / $138.04
| Facility | | $54.95 | $69.18 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $69.18 / $263.03
| Professional | | $69.18 | $69.18 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $58.88 / $70.79
| Professional | | $50.12 | $58.88 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $72.44 / $72.44
| Facility | | $72.44 | $72.44 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5,888.44 / $5,888.44 / $5,888.44
| Professional | | $5,888.44 | $5,888.44 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $64.57 / $208.93
| Facility | | $58.88 | $64.57 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $309.03
| Professional | | $58.88 | $58.88 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $69.18 / $162.18
| Facility | | $69.18 | $69.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $69.18 / $72.44
| Professional | | $69.18 | $69.18 | $72.44 |