- 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
- $2.00 / $3.02 / $3.98
| Professional | | $2.00 | $3.02 | $3.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5.25 / $5.25 / $8.51
| Facility | | $5.25 | $5.25 | $8.51 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4.68 / $4.79 / $5.75
| Professional | | $4.68 | $4.79 | $5.75 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $6.17 / $6.17 / $8.13
| Facility | | $6.17 | $6.17 | $8.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3.09 / $15.85 / $25.12
| Facility | | $3.09 | $15.85 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.57 / $7.59 / $9.77
| Professional | | $2.57 | $7.59 | $9.77 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.88 / $4.37 / $7.41
| Facility | | $2.88 | $4.37 | $7.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4.57 / $9.33 / $11.75
| Professional | | $4.57 | $9.33 | $11.75 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.95 / $5.13 / $79.43
| Facility | | $2.95 | $5.13 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.14 / $2.57 / $5.50
| Professional | | $2.14 | $2.57 | $5.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.55 / $33.11 / $70.79
| Professional | | $3.55 | $33.11 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $8.13 / $8.13 / $8.13
| Facility | | $8.13 | $8.13 | $8.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.72 / $5.89 / $10.23
| Professional | | $3.72 | $5.89 | $10.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5.25 / $7.76 / $13.80
| Professional | | $5.25 | $7.76 | $13.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3.09 / $10.23 / $79.43
| Facility | | $3.09 | $10.23 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.57 / $5.25 / $25.12
| Professional | | $2.57 | $5.25 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5.25 / $5.25 / $5.25
| Professional | | $5.25 | $5.25 | $5.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $5.25 / $5.25 / $5.25
| Professional | | $5.25 | $5.25 | $5.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.66 / $2.29 / $3.72
| Facility | | $1.66 | $2.29 | $3.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.70 / $2.51 / $4.07
| Professional | | $1.70 | $2.51 | $4.07 |