- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $199.53 / $676.08
| Professional | | $72.44 | $199.53 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $77.62 / $263.03
| Professional | 26 | $22.91 | $77.62 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $43.65 / $95.50 / $537.03
| Professional | TC | $43.65 | $95.50 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $43.65 / $87.10
| Professional | | $42.66 | $43.65 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $21.38 / $33.88
| Professional | 26 | $12.88 | $21.38 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $61.66
| Professional | TC | $30.20 | $30.20 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $102.33
| Professional | | $102.33 | $102.33 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $81.28 / $165.96
| Professional | | $41.69 | $81.28 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $26.92 / $54.95
| Professional | 26 | $12.88 | $26.92 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $27.54 / $54.95 / $112.20
| Professional | TC | $27.54 | $54.95 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $87.10 / $117.49
| Facility | | $69.18 | $87.10 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $100.00 / $562.34
| Professional | | $56.23 | $100.00 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $34.67 / $173.78
| Professional | 26 | $17.78 | $34.67 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $64.57 / $389.05
| Professional | TC | $38.90 | $64.57 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $17.38 / $43.65 / $60.26
| Facility | | $17.38 | $43.65 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $91.20 / $131.83
| Professional | | $56.23 | $91.20 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $29.51 / $41.69
| Professional | 26 | $17.78 | $29.51 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $61.66 / $91.20
| Professional | TC | $38.90 | $61.66 | $91.20 |