- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $18.20 / $18.20 / $18.20
| Facility | | $18.20 | $18.20 | $18.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.96 / $15.49 / $30.20
| Professional | | $10.96 | $15.49 | $30.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $34.67 / $40.74
| Facility | | $34.67 | $34.67 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $16.22 / $16.22 / $17.38
| Professional | | $16.22 | $16.22 | $17.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8.91 / $8.91 / $8.91
| Professional | | $8.91 | $8.91 | $8.91 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $13.49 / $21.88 / $39.81
| Facility | | $13.49 | $21.88 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.14 / $15.14 / $38.02
| Professional | | $15.14 | $15.14 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $20.89 / $21.88
| Professional | | $0.60 | $20.89 | $21.88 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $8.13 / $8.71 / $21.88
| Facility | | $8.13 | $8.71 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $7.59 / $10.23 / $14.79
| Professional | | $7.59 | $10.23 | $14.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $102.33
| Facility | | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $218.78 / $218.78
| Professional | | $158.49 | $218.78 | $218.78 |