- 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
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.00 / $2.00 / $3.72
| Facility | | $2.00 | $2.00 | $3.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.09 / $3.72 / $4.68
| Professional | | $2.09 | $3.72 | $4.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.16 / $4.79 / $5.37
| Professional | | $3.16 | $4.79 | $5.37 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.24 / $3.63 / $79.43
| Facility | | $2.24 | $3.63 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.38 / $2.00 / $5.50
| Professional | | $1.38 | $2.00 | $5.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.09 / $3.80 / $4.27
| Professional | | $3.09 | $3.80 | $4.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3.16 / $3.72 / $3.72
| Facility | | $3.16 | $3.72 | $3.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.82 / $5.50 / $5.50
| Professional | | $2.82 | $5.50 | $5.50 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.95 / $1.38 / $2.34
| Facility | | $0.95 | $1.38 | $2.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.29 / $1.66 / $3.16
| Professional | | $1.29 | $1.66 | $3.16 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.34 / $2.95 / $2.95
| Professional | | $2.34 | $2.95 | $2.95 |