- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.86 / $2.00 / $2.00
| Facility | | $1.86 | $2.00 | $2.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.00 / $2.00 / $3.02
| Professional | | $1.00 | $2.00 | $3.02 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Facility | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5.62 / $5.62 / $5.62
| Facility | | $5.62 | $5.62 | $5.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.82 / $2.82 / $2.82
| Professional | | $2.82 | $2.82 | $2.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $89.13
| Facility | | $89.13 | $89.13 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.18 / $28.18 / $29.51
| Professional | | $28.18 | $28.18 | $29.51 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.29 / $4.07 / $6.46
| Facility | | $2.29 | $4.07 | $6.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.86 / $2.00 / $3.02
| Professional | | $1.86 | $2.00 | $3.02 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.29 / $4.07 / $6.46
| Facility | | $2.29 | $4.07 | $6.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.82 / $2.82 / $2.82
| Professional | | $2.82 | $2.82 | $2.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.32 / $2.14 / $5.62
| Facility | | $1.32 | $2.14 | $5.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.82 / $2.14 / $3.80
| Professional | | $1.82 | $2.14 | $3.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.31 / $3.31 / $3.31
| Professional | | $3.31 | $3.31 | $3.31 |