- 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
- $2.00 / $2.00 / $2.00
| Facility | | $2.00 | $2.00 | $2.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.70 / $1.70 / $1.70
| Professional | | $1.70 | $1.70 | $1.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.51 / $6.03 / $7.08
| Professional | | $2.51 | $6.03 | $7.08 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.24 / $2.51 / $3.39
| Facility | | $2.24 | $2.51 | $3.39 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.45 / $2.82 / $3.72
| Professional | | $2.45 | $2.82 | $3.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.95 / $3.24 / $3.31
| Facility | | $2.95 | $3.24 | $3.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.95 / $3.31 / $3.47
| Professional | | $2.95 | $3.31 | $3.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.86 / $2.82 / $3.98
| Facility | | $1.86 | $2.82 | $3.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.70 / $3.16 / $79.43
| Professional | | $1.70 | $3.16 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.75 / $5.25 / $12.88
| Facility | | $2.75 | $5.25 | $12.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.88 / $3.72 / $3.72
| Professional | | $2.88 | $3.72 | $3.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.07 / $1.29 / $1.55
| Facility | | $1.07 | $1.29 | $1.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.26 / $1.41 / $2.69
| Professional | | $1.26 | $1.41 | $2.69 |