- 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
- $4.07 / $4.07 / $6.76
| Facility | | $4.07 | $4.07 | $6.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.80 / $3.80 / $5.25
| Professional | | $3.80 | $3.80 | $5.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.40 / $12.59 / $19.95
| Facility | | $2.40 | $12.59 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.04 / $5.62 / $7.76
| Professional | | $2.04 | $5.62 | $7.76 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.24 / $3.47 / $5.89
| Facility | | $2.24 | $3.47 | $5.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.63 / $7.24 / $8.71
| Professional | | $3.63 | $7.24 | $8.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.29 / $3.98 / $79.43
| Facility | | $2.29 | $3.98 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.70 / $2.00 / $4.68
| Professional | | $1.70 | $2.00 | $4.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.16 / $33.11 / $70.79
| Professional | | $3.16 | $33.11 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $6.46 / $6.46 / $6.46
| Facility | | $6.46 | $6.46 | $6.46 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.88 / $4.57 / $7.94
| Professional | | $2.88 | $4.57 | $7.94 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4.07 / $6.17 / $10.47
| Professional | | $4.07 | $6.17 | $10.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.40 / $8.13 / $79.43
| Facility | | $2.40 | $8.13 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.04 / $4.07 / $19.95
| Professional | | $2.04 | $4.07 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4.07 / $4.07 / $4.07
| Professional | | $4.07 | $4.07 | $4.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4.07 / $4.07 / $4.07
| Professional | | $4.07 | $4.07 | $4.07 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.17 / $2.00 / $4.07
| Facility | | $1.17 | $2.00 | $4.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.32 / $2.00 / $3.31
| Professional | | $1.32 | $2.00 | $3.31 |