- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.58 / $2.00 / $2.00
| Facility | | $1.58 | $2.00 | $2.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.00 / $1.00 / $2.00
| Professional | | $1.00 | $1.00 | $2.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.35 / $1.35 / $4.07
| Professional | | $1.35 | $1.35 | $4.07 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.86 / $2.45 / $3.89
| Facility | | $1.86 | $2.45 | $3.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.66 / $1.66 / $2.34
| Professional | | $1.66 | $1.66 | $2.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $4.90 / $4.90 / $4.90
| Professional | | $4.90 | $4.90 | $4.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.85 / $1.70 / $6.03
| Facility | | $0.85 | $1.70 | $6.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.70 / $1.70 / $1.70
| Professional | | $1.70 | $1.70 | $1.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.60 / $0.60 / $2.14
| Professional | | $0.60 | $0.60 | $2.14 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.66 / $2.45 / $2.75
| Facility | | $1.66 | $2.45 | $2.75 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.35 / $1.35 / $2.00
| Professional | | $1.35 | $1.35 | $2.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $616.60 / $616.60
| Professional | | $616.60 | $616.60 | $616.60 |