- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $181.97 / $181.97
| Facility | | $181.97 | $181.97 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $138.04 / $281.84
| Professional | | $104.71 | $138.04 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $23.99 / $53.70
| Professional | 26 | $14.79 | $23.99 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $114.82 / $194.98
| Professional | TC | $91.20 | $114.82 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $154.88 / $181.97
| Professional | | $117.49 | $154.88 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.62 / $22.91 / $28.18
| Professional | 26 | $18.62 | $22.91 | $28.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $131.83 / $151.36
| Professional | TC | $102.33 | $131.83 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $223.87 / $309.03
| Professional | | $154.88 | $223.87 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.14 / $28.18 / $45.71
| Professional | 26 | $15.14 | $28.18 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $194.98 / $281.84
| Professional | TC | $131.83 | $194.98 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $204.17 / $436.52
| Professional | | $134.90 | $204.17 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.39 / $31.62 / $34.67
| Professional | 26 | $22.39 | $31.62 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $162.18 / $398.11
| Professional | TC | $112.20 | $162.18 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $134.90 / $169.82
| Professional | | $128.82 | $134.90 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $22.39 / $25.70
| Professional | 26 | $21.88 | $22.39 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $112.20 / $144.54
| Professional | TC | $107.15 | $112.20 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $218.78 / $323.59
| Professional | | $165.96 | $218.78 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.22 / $35.48 / $57.54
| Professional | 26 | $16.22 | $35.48 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $128.82 / $186.21 / $281.84
| Professional | TC | $128.82 | $186.21 | $281.84 |