- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $602.56 / $602.56
| Facility | | $602.56 | $602.56 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $144.54 / $302.00
| Professional | | $109.65 | $144.54 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $74.13 / $288.40
| Professional | 26 | $42.66 | $74.13 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $72.44 / $158.49
| Professional | TC | $64.57 | $72.44 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $158.49
| Professional | | $83.18 | $83.18 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $33.88 / $93.33
| Professional | 26 | $33.88 | $33.88 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $50.12 / $64.57
| Professional | TC | $50.12 | $50.12 | $64.57 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $158.49 / $602.56
| Facility | | $114.82 | $158.49 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $275.42 / $478.63
| Professional | | $109.65 | $275.42 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $131.83 / $812.83
| Professional | 26 | $42.66 | $131.83 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $58.88 / $158.49 / $204.17
| Professional | TC | $58.88 | $158.49 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $676.08 / $933.25
| Professional | | $194.98 | $676.08 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $309.03 / $371.54
| Professional | 26 | $95.50 | $309.03 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $371.54 / $575.44
| Professional | TC | $97.72 | $371.54 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $158.49 / $218.78
| Facility | | $114.82 | $158.49 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $158.49
| Professional | | $83.18 | $83.18 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $33.88 / $93.33
| Professional | 26 | $33.88 | $33.88 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $50.12 / $64.57
| Professional | TC | $50.12 | $50.12 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $263.03 / $588.84
| Professional | | $158.49 | $263.03 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $104.71 / $302.00
| Professional | 26 | $74.13 | $104.71 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $83.18 / $162.18 / $281.84
| Professional | TC | $83.18 | $162.18 | $281.84 |