- 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 / $1.00 / $2.00
| Professional | | $1.00 | $1.00 | $2.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.86 / $1.86 / $1.86
| Facility | | $1.86 | $1.86 | $1.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.58 / $1.58 / $1.58
| Professional | | $1.58 | $1.58 | $1.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.19 / $6.03 / $6.92
| Professional | | $2.19 | $6.03 | $6.92 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.19 / $2.40 / $3.24
| Facility | | $2.19 | $2.40 | $3.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.29 / $2.51 / $3.63
| Professional | | $2.29 | $2.51 | $3.63 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.45 / $3.02 / $3.09
| Facility | | $2.45 | $3.02 | $3.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.69 / $3.09 / $3.39
| Professional | | $2.69 | $3.09 | $3.39 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.78 / $2.69 / $3.72
| Facility | | $1.78 | $2.69 | $3.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.58 / $2.95 / $79.43
| Professional | | $1.58 | $2.95 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.69 / $3.47 / $3.47
| Professional | | $2.69 | $3.47 | $3.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.00 / $1.20 / $1.45
| Facility | | $1.00 | $1.20 | $1.45 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.17 / $1.32 / $2.51
| Professional | | $1.17 | $1.32 | $2.51 |