- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19.95 / $19.95 / $19.95
| Facility | | $19.95 | $19.95 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.00 / $15.14 / $19.95
| Professional | | $10.00 | $15.14 | $19.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $23.44 / $31.62 / $31.62
| Facility | | $23.44 | $31.62 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $17.78 / $17.78 / $19.05
| Professional | | $17.78 | $17.78 | $19.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12.02 / $12.02 / $12.02
| Professional | | $12.02 | $12.02 | $12.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16.98 / $16.98 / $16.98
| Professional | | $16.98 | $16.98 | $16.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $14.13 / $22.39 / $34.67
| Facility | | $14.13 | $22.39 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $14.45 / $14.45 / $41.69
| Professional | | $14.45 | $14.45 | $41.69 |
- 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
- $7.76 / $9.55 / $23.99
| Facility | | $7.76 | $9.55 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8.32 / $11.75 / $16.60
| Professional | | $8.32 | $11.75 | $16.60 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Facility | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $177.83
| Professional | | $120.23 | $120.23 | $177.83 |