- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $15.85 / $15.85 / $15.85
| Facility | | $15.85 | $15.85 | $15.85 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8.91 / $14.13 / $15.85
| Professional | | $8.91 | $14.13 | $15.85 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $11.22 / $17.38 / $20.42
| Professional | | $11.22 | $17.38 | $20.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $17.38 / $17.38 / $19.05
| Professional | | $17.38 | $17.38 | $19.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $10.23 / $14.45 / $14.45
| Facility | | $10.23 | $14.45 | $14.45 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.47 / $10.47 / $15.85
| Professional | | $10.47 | $10.47 | $15.85 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8.71 / $9.55 / $13.80
| Professional | | $8.71 | $9.55 | $13.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $9.33 / $17.78 / $31.62
| Facility | | $9.33 | $17.78 | $31.62 |
- 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
- $9.12 / $14.13 / $18.62
| Facility | | $9.12 | $14.13 | $18.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8.71 / $11.22 / $15.85
| Professional | | $8.71 | $11.22 | $15.85 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $104.71
| Facility | | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $190.55
| Professional | | $128.82 | $128.82 | $190.55 |