- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Facility | | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $51.29 / $51.29
| Facility | 26 | $51.29 | $51.29 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $75.86 / $144.54
| Professional | | $58.88 | $75.86 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $18.20 / $30.20
| Professional | 26 | $14.13 | $18.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $41.69 / $52.48 / $123.03
| Professional | TC | $41.69 | $52.48 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $154.88 / $309.03
| Professional | | $91.20 | $154.88 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $41.69 / $64.57
| Professional | 26 | $23.99 | $41.69 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $66.07 / $104.71 / $269.15
| Professional | TC | $66.07 | $104.71 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $102.33 / $257.04
| Facility | | $63.10 | $102.33 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $51.29 / $51.29
| Facility | 26 | $51.29 | $51.29 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $169.82 / $288.40
| Professional | | $63.10 | $169.82 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $47.86 / $89.13
| Professional | 26 | $16.98 | $47.86 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $44.67 / $120.23 / $199.53
| Professional | TC | $44.67 | $120.23 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $275.42 / $380.19
| Professional | | $147.91 | $275.42 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $72.44 / $93.33
| Professional | 26 | $33.11 | $72.44 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $199.53 / $309.03
| Professional | TC | $95.50 | $199.53 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $102.33 / $257.04
| Facility | | $63.10 | $102.33 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $169.82 / $199.53
| Professional | | $91.20 | $169.82 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $32.36 / $64.57
| Professional | 26 | $17.78 | $32.36 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $46.77 / $89.13 / $269.15
| Professional | TC | $46.77 | $89.13 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $52.48 / $162.18 / $323.59
| Professional | | $52.48 | $162.18 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $52.48 / $112.20
| Professional | 26 | $18.20 | $52.48 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $45.71 / $123.03 / $218.78
| Professional | TC | $45.71 | $123.03 | $218.78 |