- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $10.00 / $10.00 / $10.00
| Facility | | $10.00 | $10.00 | $10.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.00 / $12.88 / $16.98
| Professional | | $10.00 | $12.88 | $16.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16.22 / $16.22 / $16.22
| Professional | | $16.22 | $16.22 | $16.22 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $57.54 / $57.54
| Professional | | $57.54 | $57.54 | $57.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $32.36 / $32.36
| Facility | | $32.36 | $32.36 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.14 / $15.14 / $15.14
| Professional | | $15.14 | $15.14 | $15.14 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $114.82
| Facility | | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $151.36 / $151.36
| Professional | | $144.54 | $151.36 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $10.96 / $19.95 / $35.48
| Facility | | $10.96 | $19.95 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8.91 / $12.88 / $16.98
| Professional | | $8.91 | $12.88 | $16.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $33.11 / $44.67
| Professional | | $30.20 | $33.11 | $44.67 |
- 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
- $10.96 / $19.95 / $35.48
| Facility | | $10.96 | $19.95 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.14 / $15.14 / $15.14
| Professional | | $15.14 | $15.14 | $15.14 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $9.55 / $9.55 / $9.55
| Facility | | $9.55 | $9.55 | $9.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $9.55 / $11.48 / $20.42
| Professional | | $9.55 | $11.48 | $20.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $27.54 / $27.54 / $34.67
| Professional | | $27.54 | $27.54 | $34.67 |