- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $281.84 / $281.84
| Facility | | $281.84 | $281.84 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $58.88 / $218.78
| Professional | | $44.67 | $58.88 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $45.71 / $87.10
| Professional | 26 | $16.98 | $45.71 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $39.81 / $144.54
| Professional | TC | $30.90 | $39.81 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $22.39 / $57.54 / $70.79
| Professional | | $22.39 | $57.54 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $20.89 / $25.70
| Professional | 26 | $17.78 | $20.89 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $43.65 / $47.86
| Professional | TC | $38.02 | $43.65 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.20 / $39.81 / $117.49
| Professional | | $30.20 | $39.81 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $0.25 / $13.18 / $43.65
| Professional | 26 | $0.25 | $13.18 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $0.56 / $25.12 / $81.28
| Professional | TC | $0.56 | $25.12 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $83.18 / $114.82
| Professional | | $72.44 | $83.18 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $26.30 / $47.86
| Professional | 26 | $21.88 | $26.30 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $51.29 / $61.66 / $77.62
| Professional | TC | $51.29 | $61.66 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $54.95 / $123.03
| Professional | | $43.65 | $54.95 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.14 / $20.89 / $43.65
| Professional | 26 | $15.14 | $20.89 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $36.31 / $70.79
| Professional | TC | $28.18 | $36.31 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $102.33 / $114.82
| Professional | | $57.54 | $102.33 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $30.20 / $33.88
| Professional | 26 | $20.89 | $30.20 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $36.31 / $72.44 / $81.28
| Professional | TC | $36.31 | $72.44 | $81.28 |