- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $47.86 / $47.86 / $47.86
| Facility | | $47.86 | $47.86 | $47.86 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $190.55 / $190.55 / $190.55
| Facility | 26 | $190.55 | $190.55 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $144.54 / $398.11
| Professional | | $102.33 | $144.54 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $131.83 / $478.63
| Professional | 26 | $52.48 | $131.83 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $75.86 / $158.49
| Professional | TC | $52.48 | $75.86 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $87.10 / $162.18
| Professional | | $81.28 | $87.10 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $79.43 / $114.82
| Professional | 26 | $32.36 | $79.43 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $83.18 / $165.96
| Professional | | $66.07 | $83.18 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $112.20 / $229.09
| Professional | | $75.86 | $112.20 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $57.54 / $112.20
| Professional | 26 | $33.88 | $57.54 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $58.88 / $123.03
| Professional | TC | $38.02 | $58.88 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $120.23 / $239.88
| Professional | | $93.33 | $120.23 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $50.12 / $75.86 / $128.82
| Professional | 26 | $50.12 | $75.86 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.99 / $56.23 / $134.90
| Professional | TC | $23.99 | $56.23 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $144.54
| Professional | | $32.36 | $33.11 | $144.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $27.54 / $50.12 / $125.89
| Facility | | $27.54 | $50.12 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $95.50 / $316.23
| Professional | | $72.44 | $95.50 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $44.67 / $151.36
| Professional | 26 | $33.88 | $44.67 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $50.12 / $165.96
| Professional | TC | $38.02 | $50.12 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $131.83 / $169.82
| Professional | | $58.88 | $131.83 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $51.29 / $66.07
| Professional | 26 | $23.44 | $51.29 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $35.48 / $79.43 / $102.33
| Professional | TC | $35.48 | $79.43 | $102.33 |