- 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
- Facility
- Modifier
- Typical Low / Median / Typical High
- $3.55 / $3.55 / $5.89
| Facility | | $3.55 | $3.55 | $5.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.24 / $3.31 / $3.89
| Professional | | $3.24 | $3.31 | $3.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.51 / $10.47 / $16.98
| Facility | | $2.51 | $10.47 | $16.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.78 / $5.13 / $6.76
| Professional | | $1.78 | $5.13 | $6.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.95 / $3.02 / $5.13
| Facility | | $1.95 | $3.02 | $5.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.16 / $5.50 / $6.61
| Professional | | $3.16 | $5.50 | $6.61 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.00 / $3.47 / $79.43
| Facility | | $2.00 | $3.47 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.48 / $1.74 / $4.07
| Professional | | $1.48 | $1.74 | $4.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.75 / $33.11 / $70.79
| Professional | | $2.75 | $33.11 | $70.79 |
- 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
- $2.51 / $3.98 / $6.92
| Professional | | $2.51 | $3.98 | $6.92 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.55 / $5.37 / $9.55
| Professional | | $3.55 | $5.37 | $9.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.09 / $7.08 / $79.43
| Facility | | $2.09 | $7.08 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.78 / $3.55 / $17.38
| Professional | | $1.78 | $3.55 | $17.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.55 / $3.55 / $3.55
| Professional | | $3.55 | $3.55 | $3.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.55 / $3.55 / $3.55
| Professional | | $3.55 | $3.55 | $3.55 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.02 / $1.74 / $3.55
| Facility | | $1.02 | $1.74 | $3.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.15 / $1.74 / $2.88
| Professional | | $1.15 | $1.74 | $2.88 |