- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $288.40 / $575.44
| Facility | | $57.54 | $288.40 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.92 / $63.10 / $75.86
| Professional | | $26.92 | $63.10 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.08 / $17.38 / $234.42
| Professional | 26 | $7.08 | $17.38 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.95 / $47.86 / $54.95
| Professional | TC | $19.95 | $47.86 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $21.38 / $66.07
| Professional | | $21.38 | $21.38 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $5.50 / $5.50 / $14.79
| Professional | 26 | $5.50 | $5.50 | $14.79 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.22 / $16.22 / $51.29
| Professional | TC | $16.22 | $16.22 | $51.29 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $70.79 / $575.44
| Facility | | $30.90 | $70.79 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.92 / $67.61 / $165.96
| Professional | | $26.92 | $67.61 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $7.41 / $21.88 / $575.44
| Professional | 26 | $7.41 | $21.88 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.95 / $51.29 / $117.49
| Professional | TC | $19.95 | $51.29 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $181.97 / $234.42
| Professional | | $57.54 | $181.97 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.14 / $48.98 / $60.26
| Professional | 26 | $15.14 | $48.98 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $41.69 / $131.83 / $173.78
| Professional | TC | $41.69 | $131.83 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $70.79 / $95.50
| Facility | | $30.90 | $70.79 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $21.38 / $66.07
| Professional | | $21.38 | $21.38 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $5.50 / $5.50 / $14.79
| Professional | 26 | $5.50 | $5.50 | $14.79 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.22 / $16.22 / $51.29
| Professional | TC | $16.22 | $16.22 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $66.07 / $147.91
| Professional | | $41.69 | $66.07 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $16.60 / $48.98
| Professional | 26 | $12.02 | $16.60 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.20 / $48.98 / $100.00
| Professional | TC | $30.20 | $48.98 | $100.00 |