- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $12.88 / $12.88 / $12.88
| Facility | | $12.88 | $12.88 | $12.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4.37 / $12.88 / $69.18
| Professional | | $4.37 | $12.88 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $13.80 / $15.14 / $15.49
| Professional | | $13.80 | $15.14 | $15.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $8.13 / $9.55 / $17.78
| Facility | | $8.13 | $9.55 | $17.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8.13 / $18.20 / $26.92
| Professional | | $8.13 | $18.20 | $26.92 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $12.88 / $22.39 / $79.43
| Facility | | $12.88 | $22.39 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5.25 / $7.94 / $15.85
| Professional | | $5.25 | $7.94 | $15.85 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $17.38 / $17.38 / $42.66
| Professional | | $17.38 | $17.38 | $42.66 |
- 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
- $21.88 / $39.81 / $42.66
| Professional | | $21.88 | $39.81 | $42.66 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4.57 / $7.24 / $10.23
| Facility | | $4.57 | $7.24 | $10.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5.50 / $7.94 / $12.30
| Professional | | $5.50 | $7.94 | $12.30 |