- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $275.42 / $275.42
| Facility | | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $190.55 / $676.08
| Professional | | $79.43 | $190.55 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $41.69 / $107.15
| Professional | 26 | $22.91 | $41.69 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $45.71 / $70.79 / $446.68
| Professional | TC | $45.71 | $70.79 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $51.29 / $102.33
| Professional | | $51.29 | $51.29 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $31.62 / $40.74
| Professional | 26 | $15.85 | $31.62 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $34.67 / $34.67 / $69.18
| Professional | TC | $34.67 | $34.67 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Professional | | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $102.33 / $194.98
| Professional | | $50.12 | $102.33 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $34.67 / $74.13
| Professional | 26 | $17.78 | $34.67 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $31.62 / $67.61 / $125.89
| Professional | TC | $31.62 | $67.61 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $125.89 / $151.36
| Facility | | $85.11 | $125.89 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $144.54 / $660.69
| Professional | | $70.79 | $144.54 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $47.86 / $275.42
| Professional | 26 | $21.88 | $47.86 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $42.66 / $91.20 / $426.58
| Professional | TC | $42.66 | $91.20 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $50.12 / $70.79
| Facility | | $21.38 | $50.12 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $104.71 / $151.36
| Professional | | $64.57 | $104.71 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $40.74 / $52.48
| Professional | 26 | $21.88 | $40.74 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $42.66 / $67.61 / $97.72
| Professional | TC | $42.66 | $67.61 | $97.72 |