- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $134.90
| Facility | TC | $134.90 | $134.90 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.85 / $24.55 / $54.95
| Professional | | $15.85 | $24.55 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.76 / $12.02 / $31.62
| Professional | 26 | $6.76 | $12.02 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $14.13 / $19.05 / $40.74
| Professional | TC | $14.13 | $19.05 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $11.48 / $11.48 / $33.88
| Professional | | $11.48 | $11.48 | $33.88 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.48 / $11.48 / $14.45
| Facility | 26 | $11.48 | $11.48 | $14.45 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.39 / $22.39 / $28.18
| Facility | TC | $22.39 | $22.39 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.42 / $33.88 / $54.95
| Professional | | $20.42 | $33.88 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.17 / $11.48 / $19.50
| Professional | 26 | $6.17 | $11.48 | $19.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $14.45 / $22.39 / $35.48
| Professional | TC | $14.45 | $22.39 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $38.02 / $56.23
| Professional | | $37.15 | $38.02 | $56.23 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.48 / $11.48 / $14.45
| Facility | 26 | $11.48 | $11.48 | $14.45 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.39 / $22.39 / $28.18
| Facility | TC | $22.39 | $22.39 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $47.86 / $57.54
| Professional | | $30.20 | $47.86 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.24 / $11.48 / $16.98
| Professional | 26 | $7.24 | $11.48 | $16.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $14.79 / $22.39 / $33.88
| Professional | TC | $14.79 | $22.39 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.88 / $23.99 / $50.12
| Professional | | $21.88 | $23.99 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.59 / $7.94 / $60.26
| Professional | 26 | $7.59 | $7.94 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $13.80 / $16.98 / $34.67
| Professional | TC | $13.80 | $16.98 | $34.67 |