- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $67.61 / $229.09
| Professional | | $43.65 | $67.61 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $25.70 / $79.43
| Professional | 26 | $12.88 | $25.70 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $42.66 / $91.20
| Professional | TC | $28.84 | $42.66 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.89 / $20.89 / $70.79
| Professional | | $20.89 | $20.89 | $70.79 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $20.89 / $25.70
| Facility | 26 | $20.89 | $20.89 | $25.70 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $48.98 / $48.98 / $61.66
| Facility | TC | $48.98 | $48.98 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $70.79 / $109.65
| Professional | | $40.74 | $70.79 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.49 / $21.88 / $38.02
| Professional | 26 | $13.49 | $21.88 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.92 / $45.71 / $74.13
| Professional | TC | $26.92 | $45.71 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $79.43 / $117.49
| Professional | | $75.86 | $79.43 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $20.89 / $25.70
| Facility | 26 | $20.89 | $20.89 | $25.70 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $48.98 / $48.98 / $61.66
| Facility | TC | $48.98 | $48.98 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $100.00 / $120.23
| Professional | | $61.66 | $100.00 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $22.91 / $31.62
| Professional | 26 | $14.13 | $22.91 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $32.36 / $46.77 / $72.44
| Professional | TC | $32.36 | $46.77 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $47.86 / $85.11
| Professional | | $44.67 | $47.86 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $17.78 / $85.11
| Professional | 26 | $14.79 | $17.78 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $30.20 / $53.70
| Professional | TC | $28.18 | $30.20 | $53.70 |