- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.00 / $3.16 / $4.17
| Facility | | $1.00 | $3.16 | $4.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.00 / $1.00 / $2.82
| Professional | | $1.00 | $1.00 | $2.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.12 / $2.69 / $5.13
| Facility | | $1.12 | $2.69 | $5.13 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.74 / $4.17 / $11.75
| Facility | | $1.74 | $4.17 | $11.75 |
- 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
- $85.11 / $100.00 / $100.00
| Facility | | $85.11 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.74 / $2.51 / $3.55
| Facility | | $1.74 | $2.51 | $3.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.00 / $1.58 / $3.02
| Professional | | $1.00 | $1.58 | $3.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.58 / $1.58 / $1.66
| Professional | | $1.58 | $1.58 | $1.66 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.74 / $2.51 / $5.50
| Facility | | $1.74 | $2.51 | $5.50 |
- 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
- $1.74 / $1.74 / $2.69
| Facility | | $1.74 | $1.74 | $2.69 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.62 / $1.74 / $1.74
| Professional | | $1.62 | $1.74 | $1.74 |