- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $21.88 / $21.88 / $21.88
| Facility | | $21.88 | $21.88 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16.60 / $21.88 / $33.11
| Professional | | $16.60 | $21.88 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $28.84 / $28.84
| Professional | | $28.84 | $28.84 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $33.88 / $33.88
| Professional | | $33.88 | $33.88 | $33.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $24.55 / $24.55 / $37.15
| Facility | | $24.55 | $24.55 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.42 / $20.42 / $31.62
| Professional | | $20.42 | $20.42 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.30 / $30.20 / $41.69
| Professional | | $26.30 | $30.20 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $58.88
| Professional | | $30.20 | $30.20 | $58.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $16.60 / $22.39 / $61.66
| Facility | | $16.60 | $22.39 | $61.66 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.51 / $8.32 / $53.70
| Facility | | $2.51 | $8.32 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.51 / $6.46 / $52.48
| Professional | | $2.51 | $6.46 | $52.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.00 / $16.60 / $28.84
| Facility | | $2.00 | $16.60 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.95 / $24.55 / $38.90
| Professional | | $19.95 | $24.55 | $38.90 |