- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $446.68 / $446.68 / $446.68
| Facility | TC | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $79.43 / $213.80
| Professional | | $46.77 | $79.43 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.49 / $22.91 / $47.86
| Professional | 26 | $13.49 | $22.91 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $29.51 / $29.51 / $29.51
| Professional | 50 | $29.51 | $29.51 | $29.51 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.11 / $56.23 / $109.65
| Professional | TC | $33.11 | $56.23 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.88 / $85.11 / $85.11
| Professional | | $21.88 | $85.11 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $21.88 / $27.54
| Facility | 26 | $21.88 | $21.88 | $27.54 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $77.62
| Facility | TC | $63.10 | $63.10 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $69.18 / $128.82
| Professional | | $38.90 | $69.18 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $21.88 / $37.15
| Professional | 26 | $12.02 | $21.88 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.92 / $48.98 / $95.50
| Professional | TC | $26.92 | $48.98 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $93.33 / $141.25
| Professional | | $77.62 | $93.33 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $21.88 / $27.54
| Facility | 26 | $21.88 | $21.88 | $27.54 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $77.62
| Facility | TC | $63.10 | $63.10 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $120.23 / $144.54
| Professional | | $67.61 | $120.23 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $21.88 / $32.36
| Professional | 26 | $14.79 | $21.88 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $57.54 / $91.20
| Professional | TC | $38.02 | $57.54 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $52.48 / $93.33
| Professional | | $48.98 | $52.48 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.14 / $16.22 / $85.11
| Professional | 26 | $15.14 | $16.22 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.88 / $37.15 / $66.07
| Professional | TC | $33.88 | $37.15 | $66.07 |