- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $616.60 / $616.60
| Facility | | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $104.71
| Facility | 26 | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $151.36 / $467.74
| Professional | | $104.71 | $151.36 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $70.79 / $380.19
| Professional | 26 | $28.18 | $70.79 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $104.71 / $234.42
| Professional | TC | $63.10 | $104.71 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $85.11 / $234.42
| Professional | | $83.18 | $85.11 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $56.23 / $63.10
| Professional | 26 | $14.13 | $56.23 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $134.90 / $181.97
| Professional | | $104.71 | $134.90 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $117.49 / $251.19
| Professional | | $60.26 | $117.49 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.62 / $31.62 / $63.10
| Professional | 26 | $18.62 | $31.62 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $39.81 / $81.28 / $194.98
| Professional | TC | $39.81 | $81.28 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $128.82 / $229.09
| Professional | | $83.18 | $128.82 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $41.69 / $67.61
| Professional | 26 | $28.18 | $41.69 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $54.95 / $85.11 / $181.97
| Professional | TC | $54.95 | $85.11 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $165.96
| Professional | | $32.36 | $33.11 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $15.14 / $56.23 / $141.25
| Facility | | $15.14 | $56.23 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $104.71 / $354.81
| Professional | | $70.79 | $104.71 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $25.12 / $87.10
| Professional | 26 | $18.20 | $25.12 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $45.71 / $77.62 / $263.03
| Professional | TC | $45.71 | $77.62 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $109.65 / $173.78
| Professional | | $48.98 | $109.65 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.72 / $23.99 / $36.31
| Professional | 26 | $10.72 | $23.99 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $85.11 / $138.04
| Professional | TC | $38.90 | $85.11 | $138.04 |