- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $15.85 / $15.85 / $15.85
| Facility | | $15.85 | $15.85 | $15.85 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $14.13 / $15.85 / $26.30
| Professional | | $14.13 | $15.85 | $26.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.85 / $15.85 / $15.85
| Professional | | $15.85 | $15.85 | $15.85 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $17.38 / $30.20 / $38.90
| Professional | | $17.38 | $30.20 | $38.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $26.92 / $26.92 / $26.92
| Facility | | $26.92 | $26.92 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.85 / $21.88 / $38.02
| Professional | | $15.85 | $21.88 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22.39 / $22.39 / $22.39
| Professional | | $22.39 | $22.39 | $22.39 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $15.85 / $19.50 / $30.20
| Facility | | $15.85 | $19.50 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.14 / $15.14 / $37.15
| Professional | | $15.14 | $15.14 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16.98 / $23.99 / $26.92
| Professional | | $16.98 | $23.99 | $26.92 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $17.78 / $17.78 / $17.78
| Facility | | $17.78 | $17.78 | $17.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12.88 / $16.60 / $28.84
| Professional | | $12.88 | $16.60 | $28.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Facility | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $134.90
| Professional | | $123.03 | $123.03 | $134.90 |