- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $660.69 / $660.69 / $676.08
| Facility | | $660.69 | $660.69 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $134.90 / $288.40
| Professional | | $104.71 | $134.90 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $23.99 / $52.48
| Professional | 26 | $15.85 | $23.99 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $112.20 / $190.55
| Professional | TC | $91.20 | $112.20 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $20.89 / $134.90 / $204.17
| Professional | | $20.89 | $134.90 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.49 / $19.50 / $38.90
| Professional | 26 | $15.49 | $19.50 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $128.82 / $177.83
| Professional | TC | $114.82 | $128.82 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $199.53 / $331.13
| Professional | | $131.83 | $199.53 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.80 / $24.55 / $48.98
| Professional | 26 | $13.80 | $24.55 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $120.23 / $177.83 / $281.84
| Professional | TC | $120.23 | $177.83 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $169.82 / $239.88
| Professional | | $123.03 | $169.82 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $24.55 / $35.48
| Professional | 26 | $16.98 | $24.55 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $144.54 / $204.17
| Professional | TC | $104.71 | $144.54 | $204.17 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19.95 / $114.82 / $134.90
| Facility | | $19.95 | $114.82 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $190.55 / $323.59
| Professional | | $134.90 | $190.55 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.48 / $24.55 / $43.65
| Professional | 26 | $11.48 | $24.55 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $117.49 / $165.96 / $281.84
| Professional | TC | $117.49 | $165.96 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $151.36 / $204.17
| Professional | | $109.65 | $151.36 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.62 / $24.55 / $33.88
| Professional | 26 | $18.62 | $24.55 | $33.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $125.89 / $169.82
| Professional | TC | $91.20 | $125.89 | $169.82 |