- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $6.03 / $6.03 / $6.03
| Facility | | $6.03 | $6.03 | $6.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.02 / $4.90 / $6.03
| Professional | | $3.02 | $4.90 | $6.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $11.75 / $11.75 / $13.80
| Facility | | $11.75 | $11.75 | $13.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5.50 / $5.50 / $5.89
| Professional | | $5.50 | $5.50 | $5.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.02 / $3.02 / $3.02
| Professional | | $3.02 | $3.02 | $3.02 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4.57 / $7.41 / $12.59
| Facility | | $4.57 | $7.41 | $12.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8.91 / $8.91 / $12.59
| Professional | | $8.91 | $8.91 | $12.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $7.08 / $7.41
| Professional | | $0.60 | $7.08 | $7.41 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.75 / $2.95 / $7.41
| Facility | | $2.75 | $2.95 | $7.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.51 / $3.47 / $5.01
| Professional | | $2.51 | $3.47 | $5.01 |
- 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
- $53.70 / $66.07 / $66.07
| Professional | | $53.70 | $66.07 | $66.07 |