- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $275.42 / $275.42
| Facility | | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $275.42 / $275.42 / $275.42
| Facility | TC | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $34.67 / $53.70 / $93.33
| Professional | | $34.67 | $53.70 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $23.99 / $33.11
| Professional | 26 | $16.98 | $23.99 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $12.88 / $20.42 / $64.57
| Professional | TC | $12.88 | $20.42 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $67.61 / $67.61
| Professional | | $53.70 | $67.61 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $37.15 / $37.15
| Professional | 26 | $30.20 | $37.15 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $23.99 / $30.20 / $30.20
| Professional | TC | $23.99 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $102.33 / $208.93
| Professional | | $58.88 | $102.33 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $37.15 / $67.61
| Professional | 26 | $21.88 | $37.15 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $72.44 / $151.36
| Professional | TC | $28.84 | $72.44 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $14.79 / $33.11 / $47.86
| Facility | | $14.79 | $33.11 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $93.33 / $204.17
| Professional | | $64.57 | $93.33 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.39 / $38.90 / $74.13
| Professional | 26 | $22.39 | $38.90 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $31.62 / $57.54 / $134.90
| Professional | TC | $31.62 | $57.54 | $134.90 |