- 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 / $11.75
| Professional | | $1.00 | $2.00 | $11.75 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.40 / $2.63 / $2.63
| Professional | | $2.40 | $2.63 | $2.63 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.62 / $1.62 / $3.09
| Facility | | $1.62 | $1.62 | $3.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.62 / $3.02 / $4.68
| Professional | | $1.62 | $3.02 | $4.68 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.19 / $3.80 / $79.43
| Facility | | $2.19 | $3.80 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.91 / $1.35 / $2.88
| Professional | | $0.91 | $1.35 | $2.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.02 / $3.02 / $7.41
| Professional | | $3.02 | $3.02 | $7.41 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3.09 / $3.09 / $3.09
| Facility | | $3.09 | $3.09 | $3.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.80 / $6.76 / $7.41
| Professional | | $3.80 | $6.76 | $7.41 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.78 / $1.23 / $1.78
| Facility | | $0.78 | $1.23 | $1.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.95 / $1.35 / $2.14
| Professional | | $0.95 | $1.35 | $2.14 |