- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $6.03 / $6.03 / $6.03
| Facility | | $6.03 | $6.03 | $6.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.09 / $3.98 / $6.03
| Professional | | $2.09 | $3.98 | $6.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $6.92 / $9.33 / $9.33
| Facility | | $6.92 | $9.33 | $9.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5.25 / $5.25 / $5.62
| Professional | | $5.25 | $5.25 | $5.62 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4.07 / $4.17 / $4.37
| Facility | | $4.07 | $4.17 | $4.37 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.55 / $3.55 / $4.90
| Professional | | $3.55 | $3.55 | $4.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.24 / $3.47 / $4.90
| Professional | | $3.24 | $3.47 | $4.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3.02 / $6.03 / $10.00
| Facility | | $3.02 | $6.03 | $10.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $0.60 / $0.60
| Professional | | $0.60 | $0.60 | $0.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.04 / $2.88 / $4.90
| Facility | | $2.04 | $2.88 | $4.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.45 / $3.39 / $5.01
| Professional | | $2.45 | $3.39 | $5.01 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $85.11
| Facility | | $79.43 | $79.43 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $34.67 / $218.78
| Professional | | $34.67 | $34.67 | $218.78 |