- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.00 / $2.00 / $2.00
| Facility | | $2.00 | $2.00 | $2.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.00 / $2.00 / $2.00
| Professional | | $1.00 | $2.00 | $2.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.09 / $3.09 / $5.75
| Professional | | $3.09 | $3.09 | $5.75 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $6.03 / $6.03 / $6.03
| Professional | | $6.03 | $6.03 | $6.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.51 / $1.51 / $1.51
| Facility | | $1.51 | $1.51 | $1.51 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.29 / $1.29 / $2.57
| Professional | | $1.29 | $1.29 | $2.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.82 / $3.55 / $6.17
| Professional | | $2.82 | $3.55 | $6.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.04 / $3.16 / $6.03
| Facility | | $2.04 | $3.16 | $6.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.19 / $2.57 / $3.16
| Professional | | $2.19 | $2.57 | $3.16 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.88 / $3.89 / $100.00
| Facility | | $2.88 | $3.89 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.88 / $3.89 / $100.00
| Professional | | $2.88 | $3.89 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5.25 / $5.25 / $5.25
| Facility | | $5.25 | $5.25 | $5.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.82 / $2.40 / $4.68
| Professional | | $1.82 | $2.40 | $4.68 |