- 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
- $3.89 / $3.89 / $3.89
| Professional | | $3.89 | $3.89 | $3.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $5.01 / $11.48 / $21.88
| Facility | | $5.01 | $11.48 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.80 / $3.80 / $3.98
| Professional | | $3.80 | $3.80 | $3.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.29 / $4.57 / $8.13
| Facility | | $2.29 | $4.57 | $8.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.80 / $5.25 / $5.37
| Professional | | $3.80 | $5.25 | $5.37 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.29 / $2.29 / $2.40
| Facility | | $2.29 | $2.29 | $2.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.82 / $1.82 / $2.69
| Professional | | $1.82 | $1.82 | $2.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.40 / $2.69 / $7.94
| Facility | | $2.40 | $2.69 | $7.94 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.00 / $3.02 / $4.68
| Professional | | $2.00 | $3.02 | $4.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.29 / $2.29 / $2.40
| Facility | | $2.29 | $2.29 | $2.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.82 / $1.82 / $2.69
| Professional | | $1.82 | $1.82 | $2.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.05 / $1.45 / $2.40
| Facility | | $1.05 | $1.45 | $2.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.26 / $1.78 / $2.69
| Professional | | $1.26 | $1.78 | $2.69 |