- 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
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.69 / $2.69 / $2.69
| Facility | | $2.69 | $2.69 | $2.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.29 / $2.29 / $2.29
| Professional | | $2.29 | $2.29 | $2.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.88 / $8.13 / $9.33
| Professional | | $2.88 | $8.13 | $9.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.69 / $3.02 / $4.17
| Facility | | $2.69 | $3.02 | $4.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.82 / $3.02 / $4.47
| Professional | | $2.82 | $3.02 | $4.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3.02 / $3.72 / $4.37
| Facility | | $3.02 | $3.72 | $4.37 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.80 / $3.80 / $4.47
| Professional | | $3.80 | $3.80 | $4.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.45 / $3.47 / $4.79
| Facility | | $2.45 | $3.47 | $4.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.29 / $3.63 / $79.43
| Professional | | $2.29 | $3.63 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.63 / $4.27 / $4.27
| Professional | | $3.63 | $4.27 | $4.27 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.45 / $1.74 / $2.95
| Facility | | $1.45 | $1.74 | $2.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.48 / $1.91 / $3.63
| Professional | | $1.48 | $1.91 | $3.63 |