- 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
- $3.02 / $3.98 / $6.03
| Professional | | $3.02 | $3.98 | $6.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5.25 / $5.25 / $5.25
| Professional | | $5.25 | $5.25 | $5.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $7.76 / $7.76 / $7.76
| Facility | | $7.76 | $7.76 | $7.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5.62 / $5.62 / $6.03
| Professional | | $5.62 | $5.62 | $6.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.80 / $3.80 / $3.80
| Professional | | $3.80 | $3.80 | $3.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5.25 / $5.25 / $5.25
| Professional | | $5.25 | $5.25 | $5.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4.47 / $7.08 / $10.72
| Facility | | $4.47 | $7.08 | $10.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4.57 / $4.57 / $12.88
| Professional | | $4.57 | $4.57 | $12.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.40 / $3.02 / $7.59
| Facility | | $2.40 | $3.02 | $7.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.63 / $3.63 / $5.25
| Professional | | $2.63 | $3.63 | $5.25 |
- 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
- $37.15 / $37.15 / $288.40
| Professional | | $37.15 | $37.15 | $288.40 |