- 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 / $3.02
| Professional | | $1.00 | $2.00 | $3.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $12.30 / $12.30 / $22.91
| Professional | | $12.30 | $12.30 | $22.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $7.24 / $7.24 / $7.24
| Professional | | $7.24 | $7.24 | $7.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.88 / $2.88 / $2.88
| Facility | | $2.88 | $2.88 | $2.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.14 / $2.14 / $2.14
| Professional | | $2.14 | $2.14 | $2.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.16 / $3.98 / $6.76
| Professional | | $3.16 | $3.98 | $6.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.29 / $3.39 / $6.61
| Facility | | $2.29 | $3.39 | $6.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.45 / $2.82 / $3.47
| Professional | | $2.45 | $2.82 | $3.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3.16 / $4.27 / $100.00
| Facility | | $3.16 | $4.27 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.16 / $4.27 / $100.00
| Professional | | $3.16 | $4.27 | $100.00 |
- 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
- $2.00 / $2.63 / $4.79
| Professional | | $2.00 | $2.63 | $4.79 |