- 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 / $13.80
| Professional | | $1.00 | $2.00 | $13.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.75 / $3.02 / $3.09
| Professional | | $2.75 | $3.02 | $3.09 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.91 / $1.91 / $3.55
| Facility | | $1.91 | $1.91 | $3.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.91 / $3.72 / $5.37
| Professional | | $1.91 | $3.72 | $5.37 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.57 / $4.57 / $89.13
| Facility | | $2.57 | $4.57 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.12 / $1.78 / $3.98
| Professional | | $1.12 | $1.78 | $3.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.47 / $3.47 / $8.51
| Professional | | $3.47 | $3.47 | $8.51 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3.55 / $3.55 / $3.55
| Facility | | $3.55 | $3.55 | $3.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4.37 / $7.76 / $8.51
| Professional | | $4.37 | $7.76 | $8.51 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.23 / $2.19 / $3.80
| Facility | | $1.23 | $2.19 | $3.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.12 / $1.58 / $3.80
| Professional | | $1.12 | $1.58 | $3.80 |