- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $51.29 / $134.90
| Facility | | $51.29 | $51.29 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $51.29 / $69.18
| Professional | | $51.29 | $51.29 | $69.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $269.15 / $323.59
| Facility | | $204.17 | $269.15 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $51.29 / $87.10
| Professional | | $51.29 | $51.29 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $120.23 / $257.04
| Professional | | $40.74 | $120.23 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $33.11 / $85.11 / $263.03
| Facility | | $33.11 | $85.11 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $51.29 / $51.29
| Professional | | $51.29 | $51.29 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $56.23 / $72.44
| Professional | | $51.29 | $56.23 | $72.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $66.07 / $93.33
| Facility | | $51.29 | $66.07 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $51.29 / $107.15
| Professional | | $51.29 | $51.29 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $56.23 / $107.15
| Facility | | $38.02 | $56.23 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $58.88 / $107.15
| Professional | | $43.65 | $58.88 | $107.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $51.29 / $61.66
| Facility | | $30.90 | $51.29 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $26.30 / $58.88
| Professional | | $21.38 | $26.30 | $58.88 |