- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Facility | | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $18.20 / $25.12 / $33.88
| Professional | | $18.20 | $25.12 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $2.00 / $3.02 / $6.76
| Professional | 26 | $2.00 | $3.02 | $6.76 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.85 / $24.55 / $30.20
| Professional | TC | $15.85 | $24.55 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $41.69 / $41.69
| Professional | | $33.88 | $41.69 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $3.98 / $5.01 / $5.01
| Professional | 26 | $3.98 | $5.01 | $5.01 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.20 / $37.15 / $37.15
| Professional | TC | $30.20 | $37.15 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.92 / $41.69 / $58.88
| Professional | | $26.92 | $41.69 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $4.27 / $6.46 / $14.45
| Professional | 26 | $4.27 | $6.46 | $14.45 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.91 / $35.48 / $48.98
| Professional | TC | $22.91 | $35.48 | $48.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1.95 / $10.47 / $12.59
| Facility | | $1.95 | $10.47 | $12.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $31.62 / $45.71 / $91.20
| Professional | | $31.62 | $45.71 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $4.57 / $7.76 / $16.22
| Professional | 26 | $4.57 | $7.76 | $16.22 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.92 / $37.15 / $77.62
| Professional | TC | $26.92 | $37.15 | $77.62 |