- 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
- $2.24 / $3.39 / $3.47
| Professional | | $2.24 | $3.39 | $3.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4.47 / $10.23 / $19.50
| Facility | | $4.47 | $10.23 | $19.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.39 / $3.39 / $3.55
| Professional | | $3.39 | $3.39 | $3.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.19 / $2.19 / $2.19
| Facility | | $2.19 | $2.19 | $2.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.82 / $2.04 / $2.04
| Facility | | $1.82 | $2.04 | $2.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.74 / $2.14 / $2.40
| Professional | | $1.74 | $2.14 | $2.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.63 / $13.80 / $15.49
| Facility | | $2.63 | $13.80 | $15.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.00 / $2.69 / $4.37
| Professional | | $2.00 | $2.69 | $4.37 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.82 / $2.04 / $2.04
| Facility | | $1.82 | $2.04 | $2.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.82 / $2.14 / $2.40
| Professional | | $1.82 | $2.14 | $2.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.93 / $1.29 / $2.14
| Facility | | $0.93 | $1.29 | $2.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.12 / $1.58 / $2.40
| Professional | | $1.12 | $1.58 | $2.40 |