- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.00 / $72.44 / $1,000.00
| Facility | | $1.00 | $72.44 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.00 / $1.00 / $2.00
| Professional | | $1.00 | $1.00 | $2.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.95 / $1.95 / $1.95
| Facility | | $1.95 | $1.95 | $1.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.95 / $1.95 / $1.95
| Professional | | $1.95 | $1.95 | $1.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.74 / $3.39 / $3.47
| Facility | | $1.74 | $3.39 | $3.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.74 / $1.74 / $1.74
| Professional | | $1.74 | $1.74 | $1.74 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.63 / $5.01 / $22.91
| Facility | | $2.63 | $5.01 | $22.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.75 / $4.68 / $22.91
| Professional | | $2.75 | $4.68 | $22.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.95 / $2.88 / $50.12
| Professional | | $1.95 | $2.88 | $50.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.95 / $1.95 / $15.49
| Facility | | $1.95 | $1.95 | $15.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.95 / $1.95 / $1.95
| Facility | | $1.95 | $1.95 | $1.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.95 / $1.95 / $1.95
| Professional | | $1.95 | $1.95 | $1.95 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.95 / $1.95 / $1.95
| Facility | | $1.95 | $1.95 | $1.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.95 / $1.95 / $2.04
| Professional | | $1.95 | $1.95 | $2.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.70 / $1.70 / $25.12
| Facility | | $1.70 | $1.70 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.70 / $1.74 / $2.04
| Professional | | $1.70 | $1.74 | $2.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.95 / $2.45 / $2.57
| Professional | | $1.95 | $2.45 | $2.57 |