- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $204.17 / $354.81 / $630.96
| Facility | TC | $204.17 | $354.81 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.89 / $57.54 / $190.55
| Professional | | $20.89 | $57.54 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.72 / $21.38 / $57.54
| Professional | 26 | $10.72 | $21.38 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $36.31 / $114.82 / $380.19
| Professional | 50 | $36.31 | $114.82 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $31.62 / $60.26 / $112.20
| Professional | TC | $31.62 | $60.26 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $17.38 / $74.13 / $74.13
| Professional | | $17.38 | $74.13 | $74.13 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.38 / $17.38 / $21.38
| Facility | 26 | $17.38 | $17.38 | $21.38 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $57.54 / $70.79
| Facility | TC | $57.54 | $57.54 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $64.57 / $112.20
| Professional | | $37.15 | $64.57 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $9.77 / $17.38 / $27.54
| Professional | 26 | $9.77 | $17.38 | $27.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.30 / $45.71 / $85.11
| Professional | TC | $26.30 | $45.71 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $81.28 / $123.03
| Professional | | $66.07 | $81.28 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.38 / $17.38 / $21.38
| Facility | 26 | $17.38 | $17.38 | $21.38 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $57.54 / $70.79
| Facility | TC | $57.54 | $57.54 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $104.71 / $123.03
| Professional | | $54.95 | $104.71 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.72 / $17.38 / $25.12
| Professional | 26 | $10.72 | $17.38 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $34.67 / $50.12 / $83.18
| Professional | TC | $34.67 | $50.12 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $44.67 / $89.13
| Professional | | $39.81 | $44.67 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.22 / $11.75 / $31.62
| Professional | 26 | $11.22 | $11.75 | $31.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $33.11 / $58.88
| Professional | TC | $28.18 | $33.11 | $58.88 |