- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $95.50
| Facility | | $95.50 | $95.50 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.00 / $25.70 / $30.20
| Professional | | $10.00 | $25.70 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.00 / $4.79 / $10.00
| Professional | 26 | $2.00 | $4.79 | $10.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $7.08 / $18.62 / $23.44
| Professional | TC | $7.08 | $18.62 | $23.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8.13 / $8.13 / $22.91
| Professional | | $8.13 | $8.13 | $22.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.14 / $2.14 / $5.37
| Professional | 26 | $2.14 | $2.14 | $5.37 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $6.03 / $6.03 / $17.38
| Professional | TC | $6.03 | $6.03 | $17.38 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $11.22 / $26.30 / $95.50
| Facility | | $11.22 | $26.30 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.00 / $27.54 / $66.07
| Professional | | $10.00 | $27.54 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.63 / $8.13 / $74.13
| Professional | 26 | $2.63 | $8.13 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $7.08 / $19.05 / $42.66
| Professional | TC | $7.08 | $19.05 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $19.50 / $67.61 / $91.20
| Professional | | $19.50 | $67.61 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.17 / $19.50 / $23.99
| Professional | 26 | $6.17 | $19.50 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $13.18 / $47.86 / $67.61
| Professional | TC | $13.18 | $47.86 | $67.61 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $11.22 / $26.30 / $33.11
| Facility | | $11.22 | $26.30 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $8.13 / $8.13 / $22.91
| Professional | | $8.13 | $8.13 | $22.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.14 / $2.14 / $5.37
| Professional | 26 | $2.14 | $2.14 | $5.37 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $6.03 / $6.03 / $17.38
| Professional | TC | $6.03 | $6.03 | $17.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $15.85 / $26.30 / $54.95
| Professional | | $15.85 | $26.30 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $4.68 / $6.92 / $18.62
| Professional | 26 | $4.68 | $6.92 | $18.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $11.22 / $19.05 / $37.15
| Professional | TC | $11.22 | $19.05 | $37.15 |