- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $223.87
| Facility | TC | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.05 / $38.02 / $95.50
| Professional | | $19.05 | $38.02 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.51 / $14.79 / $30.90
| Professional | 26 | $8.51 | $14.79 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.05 / $32.36 / $54.95
| Professional | TC | $19.05 | $32.36 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $14.13 / $14.13 / $52.48
| Professional | | $14.13 | $14.13 | $52.48 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $14.13 / $17.38
| Facility | 26 | $14.13 | $14.13 | $17.38 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $38.02 / $46.77
| Facility | TC | $38.02 | $38.02 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $23.99 / $41.69 / $77.62
| Professional | | $23.99 | $41.69 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.59 / $13.80 / $22.91
| Professional | 26 | $7.59 | $13.80 | $22.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.22 / $28.84 / $56.23
| Professional | TC | $16.22 | $28.84 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $57.54 / $85.11
| Professional | | $47.86 | $57.54 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $14.13 / $17.38
| Facility | 26 | $14.13 | $14.13 | $17.38 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $38.02 / $46.77
| Facility | TC | $38.02 | $38.02 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $72.44 / $87.10
| Professional | | $41.69 | $72.44 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $9.55 / $14.13 / $20.89
| Professional | 26 | $9.55 | $14.13 | $20.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.91 / $33.88 / $56.23
| Professional | TC | $22.91 | $33.88 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $32.36 / $64.57
| Professional | | $29.51 | $32.36 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $9.77 / $10.23 / $74.13
| Professional | 26 | $9.77 | $10.23 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.95 / $22.39 / $39.81
| Professional | TC | $19.95 | $22.39 | $39.81 |