- 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
- $15.85 / $18.20 / $28.18
| Professional | | $15.85 | $18.20 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22.39 / $37.15 / $45.71
| Professional | | $22.39 | $37.15 | $45.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $28.18 / $28.18
| Facility | | $28.18 | $28.18 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $17.38 / $26.30 / $45.71
| Professional | | $17.38 | $26.30 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $29.51 / $29.51
| Professional | | $29.51 | $29.51 | $29.51 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $17.38 / $21.38 / $34.67
| Facility | | $17.38 | $21.38 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $21.38 / $43.65
| Professional | | $21.38 | $21.38 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22.91 / $25.12 / $27.54
| Professional | | $22.91 | $25.12 | $27.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $18.62 / $18.62 / $18.62
| Facility | | $18.62 | $18.62 | $18.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.14 / $20.42 / $34.67
| Professional | | $15.14 | $20.42 | $34.67 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $109.65
| Facility | | $109.65 | $109.65 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $162.18
| Professional | | $162.18 | $162.18 | $162.18 |