- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19.95 / $19.95 / $19.95
| Facility | | $19.95 | $19.95 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.14 / $18.20 / $21.88
| Professional | | $15.14 | $18.20 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.85 / $20.42 / $29.51
| Professional | | $15.85 | $20.42 | $29.51 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $16.22 / $18.20 / $18.20
| Facility | | $16.22 | $18.20 | $18.20 |
- 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
- $16.98 / $22.39 / $38.90
| Professional | | $16.98 | $22.39 | $38.90 |
- 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 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $16.98 / $22.91 / $39.81
| Facility | | $16.98 | $22.91 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.85 / $19.05 / $33.11
| Professional | | $15.85 | $19.05 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16.60 / $32.36 / $33.11
| Professional | | $16.60 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $18.62 / $33.11 / $42.66
| Professional | | $18.62 | $33.11 | $42.66 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $16.98 / $23.44 / $39.81
| Facility | | $16.98 | $23.44 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16.98 / $22.91 / $43.65
| Professional | | $16.98 | $22.91 | $43.65 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $13.80 / $18.62 / $28.84
| Facility | | $13.80 | $18.62 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $14.79 / $19.95 / $31.62
| Professional | | $14.79 | $19.95 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $13.18 / $17.78 / $22.39
| Professional | | $13.18 | $17.78 | $22.39 |