- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $51.29 / $102.33
| Facility | | $51.29 | $51.29 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $51.29 / $79.43
| Professional | | $51.29 | $51.29 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $134.90 / $162.18
| Facility | | $114.82 | $134.90 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $48.98 / $70.79
| Professional | | $38.90 | $48.98 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $112.20 / $234.42
| Facility | | $42.66 | $112.20 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $51.29 / $51.29
| Professional | | $51.29 | $51.29 | $51.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $56.23 / $87.10
| Facility | | $51.29 | $56.23 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $51.29 / $51.29
| Professional | | $51.29 | $51.29 | $51.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $1,380.38 / $2,951.21
| Facility | | $1,380.38 | $1,380.38 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $77.62 / $87.10
| Professional | | $77.62 | $77.62 | $87.10 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $60.26 / $63.10
| Facility | | $30.90 | $60.26 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $30.90 / $58.88
| Professional | | $21.38 | $30.90 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $245.47 / $245.47
| Facility | | $245.47 | $245.47 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $257.04 / $389.05
| Professional | | $257.04 | $257.04 | $389.05 |