- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $131.83
| Facility | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $10.96 / $18.20 / $47.86
| Professional | | $10.96 | $18.20 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $3.02 / $4.37 / $7.08
| Professional | 26 | $3.02 | $4.37 | $7.08 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $7.08 / $10.00 / $25.12
| Professional | TC | $7.08 | $10.00 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $7.41 / $7.41 / $7.41
| Professional | | $7.41 | $7.41 | $7.41 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.04 / $4.47 / $7.08
| Professional | 26 | $2.04 | $4.47 | $7.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.89 / $20.89 / $20.89
| Professional | | $20.89 | $20.89 | $20.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $7.24 / $17.38 / $45.71
| Professional | | $7.24 | $17.38 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.19 / $4.47 / $15.14
| Professional | 26 | $2.19 | $4.47 | $15.14 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $5.37 / $10.72 / $30.90
| Professional | TC | $5.37 | $10.72 | $30.90 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $13.49 / $20.42 / $40.74
| Facility | | $13.49 | $20.42 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $9.55 / $22.39 / $123.03
| Professional | | $9.55 | $22.39 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.82 / $6.17 / $87.10
| Professional | 26 | $2.82 | $6.17 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $6.76 / $18.20 / $97.72
| Professional | TC | $6.76 | $18.20 | $97.72 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2.75 / $7.76 / $10.47
| Facility | | $2.75 | $7.76 | $10.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $9.55 / $17.38 / $23.44
| Professional | | $9.55 | $17.38 | $23.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.82 / $4.68 / $6.61
| Professional | 26 | $2.82 | $4.68 | $6.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $6.76 / $12.30 / $18.20
| Professional | TC | $6.76 | $12.30 | $18.20 |