- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $2,187.76 / $2,187.76 / $2,187.76
| Facility | | $2,187.76 | $2,187.76 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $128.82 / $223.87
| Professional | | $75.86 | $128.82 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $63.10 / $851.14
| Professional | 26 | $25.12 | $63.10 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $74.13 / $138.04
| Professional | TC | $50.12 | $74.13 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $60.26 / $125.89
| Professional | | $60.26 | $60.26 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $19.95 / $74.13
| Professional | 26 | $19.95 | $19.95 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $40.74 / $40.74 / $52.48
| Professional | TC | $40.74 | $40.74 | $52.48 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $169.82 / $2,187.76
| Facility | | $91.20 | $169.82 | $2,187.76 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $181.97 / $478.63
| Professional | | $75.86 | $181.97 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $81.28 / $1,621.81
| Professional | 26 | $40.74 | $81.28 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $120.23 / $165.96
| Professional | TC | $50.12 | $120.23 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $537.03 / $660.69
| Professional | | $169.82 | $537.03 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $181.97 / $269.15
| Professional | 26 | $72.44 | $181.97 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $354.81 / $436.52
| Professional | TC | $100.00 | $354.81 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $138.04 / $177.83
| Facility | | $91.20 | $138.04 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $60.26 / $125.89
| Professional | | $60.26 | $60.26 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $19.95 / $74.13
| Professional | 26 | $19.95 | $19.95 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $40.74 / $40.74 / $52.48
| Professional | TC | $40.74 | $40.74 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $190.55 / $457.09
| Professional | | $128.82 | $190.55 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $43.65 / $61.66 / $181.97
| Professional | 26 | $43.65 | $61.66 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $83.18 / $128.82 / $281.84
| Professional | TC | $83.18 | $128.82 | $281.84 |