- 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 / $10.96
| Professional | | $1.00 | $2.00 | $10.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.24 / $2.45 / $2.45
| Professional | | $2.24 | $2.45 | $2.45 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.70 / $1.70 / $2.82
| Facility | | $1.70 | $1.70 | $2.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.70 / $3.02 / $4.27
| Professional | | $1.70 | $3.02 | $4.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.04 / $3.55 / $79.43
| Facility | | $2.04 | $3.55 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.83 / $1.26 / $2.51
| Professional | | $0.83 | $1.26 | $2.51 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.75 / $2.75 / $6.76
| Professional | | $2.75 | $2.75 | $6.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.82 / $2.82 / $2.82
| Facility | | $2.82 | $2.82 | $2.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.55 / $6.31 / $6.76
| Professional | | $3.55 | $6.31 | $6.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.72 / $1.15 / $1.66
| Facility | | $0.72 | $1.15 | $1.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.89 / $1.26 / $2.00
| Professional | | $0.89 | $1.26 | $2.00 |