- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.00 / $1.00 / $1.00
| Facility | | $1.00 | $1.00 | $1.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.00 / $2.00 / $10.00
| Professional | | $1.00 | $2.00 | $10.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.41 / $1.70 / $13.49
| Professional | | $1.41 | $1.70 | $13.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.19 / $2.19 / $5.01
| Facility | | $2.19 | $2.19 | $5.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.19 / $2.19 / $2.19
| Professional | | $2.19 | $2.19 | $2.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.95 / $2.19 / $3.24
| Professional | | $1.95 | $2.19 | $3.24 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Facility | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $4.17 / $4.17 / $4.17
| Facility | | $4.17 | $4.17 | $4.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.10 / $1.10 / $1.10
| Professional | | $1.10 | $1.10 | $1.10 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $89.13
| Facility | | $89.13 | $89.13 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $173.78
| Professional | | $91.20 | $91.20 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.70 / $2.69 / $32.36
| Facility | | $1.70 | $2.69 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.00 / $2.00 / $7.94
| Professional | | $1.00 | $2.00 | $7.94 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $3.63 / $4.07 / $5.25
| Professional | | $3.63 | $4.07 | $5.25 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.70 / $2.69 / $32.36
| Facility | | $1.70 | $2.69 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.10 / $1.10 / $1.10
| Professional | | $1.10 | $1.10 | $1.10 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $0.85 / $1.20 / $1.82
| Facility | | $0.85 | $1.20 | $1.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $0.93 / $1.20 / $1.82
| Professional | | $0.93 | $1.20 | $1.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $2.40 / $2.69 / $2.69
| Professional | | $2.40 | $2.69 | $2.69 |