- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $25.12 / $25.12 / $25.12
| Facility | | $25.12 | $25.12 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12.88 / $25.12 / $48.98
| Professional | | $12.88 | $25.12 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $51.29 / $51.29
| Professional | | $51.29 | $51.29 | $51.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $23.99 / $23.99 / $28.18
| Facility | | $23.99 | $23.99 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.88 / $21.88 / $23.44
| Professional | | $21.88 | $21.88 | $23.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12.59 / $12.59 / $23.44
| Professional | | $12.59 | $12.59 | $23.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $13.49 / $14.45 / $18.62
| Professional | | $13.49 | $14.45 | $18.62 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $12.30 / $25.12 / $42.66
| Facility | | $12.30 | $25.12 | $42.66 |
- 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
- $8.91 / $12.88 / $19.95
| Facility | | $8.91 | $12.88 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.72 / $14.13 / $20.89
| Professional | | $10.72 | $14.13 | $20.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Facility | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $208.93
| Professional | | $151.36 | $151.36 | $208.93 |