- 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 / $2.00
| Professional | | $1.00 | $2.00 | $2.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.75 / $2.75 / $5.25
| Professional | | $2.75 | $2.75 | $5.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $6.46 / $6.46 / $6.46
| Professional | | $6.46 | $6.46 | $6.46 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.87 / $0.87 / $0.87
| Facility | | $0.87 | $0.87 | $0.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.76 / $0.76 / $0.76
| Professional | | $0.76 | $0.76 | $0.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.82 / $3.55 / $6.17
| Professional | | $2.82 | $3.55 | $6.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.04 / $3.09 / $5.75
| Facility | | $2.04 | $3.09 | $5.75 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.19 / $2.57 / $3.16
| Professional | | $2.19 | $2.57 | $3.16 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.88 / $3.63 / $100.00
| Facility | | $2.88 | $3.63 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.88 / $3.63 / $100.00
| Professional | | $2.88 | $3.63 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4.79 / $4.79 / $4.79
| Facility | | $4.79 | $4.79 | $4.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.78 / $2.40 / $4.37
| Professional | | $1.78 | $2.40 | $4.37 |