- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.00 / $4.17 / $5.75
| Facility | | $2.00 | $4.17 | $5.75 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.00 / $2.00 / $3.80
| Professional | | $2.00 | $2.00 | $3.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.57 / $6.61 / $12.59
| Facility | | $2.57 | $6.61 | $12.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.69 / $2.69 / $2.69
| Professional | | $2.69 | $2.69 | $2.69 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.51 / $5.50 / $14.79
| Facility | | $2.51 | $5.50 | $14.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.19 / $2.19 / $2.19
| Professional | | $2.19 | $2.19 | $2.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $85.11 / $85.11
| Facility | | $79.43 | $85.11 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.19 / $3.39 / $4.79
| Facility | | $2.19 | $3.39 | $4.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.00 / $2.19 / $4.07
| Professional | | $2.00 | $2.19 | $4.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.34 / $2.34 / $2.40
| Professional | | $2.34 | $2.34 | $2.40 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.34 / $3.39 / $7.08
| Facility | | $2.34 | $3.39 | $7.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.19 / $2.19 / $2.19
| Professional | | $2.19 | $2.19 | $2.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.19 / $2.19 / $3.98
| Facility | | $2.19 | $2.19 | $3.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.34 / $2.34 / $2.40
| Professional | | $2.34 | $2.34 | $2.40 |