- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $72.44 / $72.44
| Facility | | $72.44 | $72.44 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $69.18 / $114.82
| Professional | | $46.77 | $69.18 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $23.99 / $42.66
| Professional | 26 | $15.85 | $23.99 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $45.71 / $72.44
| Professional | TC | $30.90 | $45.71 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $194.98
| Professional | | $194.98 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.23 / $13.80 / $51.29
| Professional | 26 | $10.23 | $13.80 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $83.18
| Professional | | $83.18 | $83.18 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $61.66 / $125.89
| Professional | | $30.20 | $61.66 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.47 / $26.30 / $45.71
| Professional | 26 | $10.47 | $26.30 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $18.62 / $37.15 / $74.13
| Professional | TC | $18.62 | $37.15 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $63.10 / $123.03
| Professional | | $38.90 | $63.10 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.49 / $23.44 / $58.88
| Professional | 26 | $13.49 | $23.44 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.99 / $40.74 / $69.18
| Professional | TC | $23.99 | $40.74 | $69.18 |