- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19.05 / $19.05 / $19.05
| Facility | | $19.05 | $19.05 | $19.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.96 / $19.05 / $20.89
| Professional | | $10.96 | $19.05 | $20.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.50 / $19.50 / $21.88
| Professional | | $19.50 | $19.50 | $21.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $11.48 / $16.22 / $16.22
| Facility | | $11.48 | $16.22 | $16.22 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12.02 / $12.02 / $19.95
| Professional | | $12.02 | $12.02 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $13.18 / $14.13 / $18.20
| Professional | | $13.18 | $14.13 | $18.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $10.72 / $21.38 / $39.81
| Facility | | $10.72 | $21.38 | $39.81 |
- 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
- $11.22 / $19.50 / $20.89
| Facility | | $11.22 | $19.50 | $20.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.72 / $12.88 / $19.95
| Professional | | $10.72 | $12.88 | $19.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $138.04 / $138.04
| Facility | | $138.04 | $138.04 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $218.78
| Professional | | $165.96 | $165.96 | $218.78 |