- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $128.82
| Facility | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $338.84 / $380.19 / $575.44
| Facility | TC | $338.84 | $380.19 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $69.18 / $141.25
| Professional | | $32.36 | $69.18 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- 25
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $70.79
| Professional | 25 | $70.79 | $70.79 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $25.70 / $54.95
| Professional | 26 | $18.20 | $25.70 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $95.50 / $104.71 / $104.71
| Professional | 50 | $95.50 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $30.20 / $43.65 / $87.10
| Professional | 52 | $30.20 | $43.65 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $14.13 / $48.98 / $97.72
| Professional | TC | $14.13 | $48.98 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $28.84 / $72.44 / $114.82
| Professional | | $28.84 | $72.44 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.49 / $25.70 / $41.69
| Professional | 26 | $15.49 | $25.70 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $12.88 / $50.12 / $77.62
| Professional | TC | $12.88 | $50.12 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $53.70 / $114.82
| Professional | | $29.51 | $53.70 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.80 / $22.91 / $47.86
| Professional | 26 | $13.80 | $22.91 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $13.18 / $28.84 / $70.79
| Professional | TC | $13.18 | $28.84 | $70.79 |