- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5.01 / $5.01 / $5.01
| Facility | | $5.01 | $5.01 | $5.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.98 / $5.01 / $11.75
| Professional | | $3.98 | $5.01 | $11.75 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $6.46 / $10.00 / $22.39
| Facility | | $6.46 | $10.00 | $22.39 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $6.61 / $6.61 / $6.61
| Professional | | $6.61 | $6.61 | $6.61 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Facility | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $12.88 / $12.88 / $12.88
| Facility | | $12.88 | $12.88 | $12.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.39 / $3.39 / $3.39
| Professional | | $3.39 | $3.39 | $3.39 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $89.13
| Facility | | $89.13 | $89.13 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $60.26 / $112.20
| Professional | | $60.26 | $60.26 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5.25 / $8.32 / $21.88
| Facility | | $5.25 | $8.32 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.98 / $5.25 / $10.96
| Professional | | $3.98 | $5.25 | $10.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.96 / $12.59 / $30.20
| Professional | | $10.96 | $12.59 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5.25 / $8.32 / $22.39
| Facility | | $5.25 | $8.32 | $22.39 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.39 / $3.39 / $3.39
| Professional | | $3.39 | $3.39 | $3.39 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.63 / $3.72 / $5.62
| Facility | | $2.63 | $3.72 | $5.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.88 / $3.72 / $5.62
| Professional | | $2.88 | $3.72 | $5.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $7.41 / $8.32 / $8.32
| Professional | | $7.41 | $8.32 | $8.32 |