- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.00 / $2.00 / $4.90
| Facility | | $2.00 | $2.00 | $4.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.00 / $2.00 / $3.98
| Professional | | $1.00 | $2.00 | $3.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $64.57 / $64.57
| Professional | | $64.57 | $64.57 | $64.57 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3.16 / $3.16 / $3.16
| Facility | | $3.16 | $3.16 | $3.16 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.16 / $3.16 / $4.07
| Professional | | $3.16 | $3.16 | $4.07 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.19 / $2.29 / $2.29
| Facility | | $2.19 | $2.29 | $2.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.86 / $1.86 / $2.29
| Professional | | $1.86 | $1.86 | $2.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.29 / $4.27 / $7.24
| Facility | | $2.29 | $4.27 | $7.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.40 / $4.57 / $7.41
| Professional | | $2.40 | $4.57 | $7.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.51 / $2.75 / $64.57
| Professional | | $2.51 | $2.75 | $64.57 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3.24 / $3.55 / $3.63
| Facility | | $3.24 | $3.55 | $3.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.16 / $3.24 / $3.63
| Professional | | $3.16 | $3.24 | $3.63 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3.02 / $3.16 / $5.89
| Facility | | $3.02 | $3.16 | $5.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.02 / $3.02 / $3.55
| Professional | | $3.02 | $3.02 | $3.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.95 / $3.16 / $4.07
| Professional | | $2.95 | $3.16 | $4.07 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.38 / $1.62 / $2.34
| Facility | | $1.38 | $1.62 | $2.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.41 / $1.55 / $2.95
| Professional | | $1.41 | $1.55 | $2.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.09 / $3.16 / $5.50
| Professional | | $2.09 | $3.16 | $5.50 |