- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $11.75 / $11.75 / $22.39
| Facility | | $11.75 | $11.75 | $22.39 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $7.76 / $14.45 / $22.39
| Professional | | $7.76 | $14.45 | $22.39 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $0.30 / $0.30 / $0.30
| Professional | 25 | $0.30 | $0.30 | $0.30 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $13.49 / $16.98 / $20.89
| Professional | | $13.49 | $16.98 | $20.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $91.20 / $234.42
| Facility | | $48.98 | $91.20 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $11.22 / $12.02 / $22.39
| Professional | | $11.22 | $12.02 | $22.39 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $14.13 / $14.13 / $14.13
| Facility | | $14.13 | $14.13 | $14.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.14 / $15.14 / $15.14
| Professional | | $15.14 | $15.14 | $15.14 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $8.71 / $16.22 / $28.84
| Facility | | $8.71 | $16.22 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $181.97
| Professional | | $32.36 | $33.11 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $181.97 / $251.19
| Facility | | $181.97 | $181.97 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8.32 / $15.14 / $25.12
| Professional | | $8.32 | $15.14 | $25.12 |