- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,290.87 / $2,290.87 / $2,290.87
| Facility | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $109.65 / $204.17
| Professional | | $70.79 | $109.65 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $46.77 / $346.74
| Professional | 26 | $20.89 | $46.77 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $42.66 / $64.57 / $123.03
| Professional | TC | $42.66 | $64.57 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $53.70 / $102.33
| Professional | | $53.70 | $53.70 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $16.98 / $57.54
| Professional | 26 | $16.98 | $16.98 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $36.31 / $36.31 / $45.71
| Professional | TC | $36.31 | $36.31 | $45.71 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $114.82 / $2,290.87
| Facility | | $77.62 | $114.82 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $181.97 / $407.38
| Professional | | $70.79 | $181.97 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $57.54 / $467.74
| Professional | 26 | $21.38 | $57.54 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $48.98 / $114.82 / $154.88
| Professional | TC | $48.98 | $114.82 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $457.09 / $616.60
| Professional | | $131.83 | $457.09 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $151.36 / $186.21
| Professional | 26 | $70.79 | $151.36 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $302.00 / $436.52
| Professional | TC | $63.10 | $302.00 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $114.82 / $144.54
| Facility | | $77.62 | $114.82 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $53.70 / $102.33
| Professional | | $53.70 | $53.70 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $16.98 / $57.54
| Professional | 26 | $16.98 | $16.98 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $36.31 / $36.31 / $45.71
| Professional | TC | $36.31 | $36.31 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $173.78 / $389.05
| Professional | | $107.15 | $173.78 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $52.48 / $151.36
| Professional | 26 | $37.15 | $52.48 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $70.79 / $123.03 / $234.42
| Professional | TC | $70.79 | $123.03 | $234.42 |