- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.00 / $10.00 / $87.10
| Professional | | $10.00 | $10.00 | $87.10 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $17.38 / $19.50 / $19.50
| Facility | | $17.38 | $19.50 | $19.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.04 / $20.42 / $22.91
| Professional | | $2.04 | $20.42 | $22.91 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $13.80 / $13.80 / $13.80
| Facility | | $13.80 | $13.80 | $13.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $11.75 / $11.75 / $18.20
| Professional | | $11.75 | $11.75 | $18.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $20.42 / $20.42 / $25.12
| Facility | | $20.42 | $20.42 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.42 / $20.42 / $25.12
| Professional | | $20.42 | $20.42 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.14 / $19.05 / $22.91
| Professional | | $15.14 | $19.05 | $22.91 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.00 / $19.50 / $20.89
| Facility | | $2.00 | $19.50 | $20.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.00 / $2.40 / $23.99
| Professional | | $2.00 | $2.40 | $23.99 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.66 / $16.60 / $22.91
| Facility | | $1.66 | $16.60 | $22.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.66 / $3.72 / $18.62
| Professional | | $1.66 | $3.72 | $18.62 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19.50 / $19.50 / $19.50
| Facility | | $19.50 | $19.50 | $19.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.04 / $20.42 / $22.91
| Professional | | $2.04 | $20.42 | $22.91 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.02 / $9.12 / $15.14
| Facility | | $1.02 | $9.12 | $15.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.47 / $11.75 / $19.95
| Professional | | $10.47 | $11.75 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $66.07 / $66.07
| Professional | | $66.07 | $66.07 | $66.07 |