- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $794.33 / $1,288.25
| Facility | | $102.33 | $794.33 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $251.19 / $602.56
| Professional | | $154.88 | $251.19 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $51.29 / $125.89
| Professional | 26 | $37.15 | $51.29 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $173.78 / $338.84
| Professional | TC | $93.33 | $173.78 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $199.53 / $223.87
| Professional | | $138.04 | $199.53 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $43.65 / $50.12
| Professional | 26 | $38.90 | $43.65 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $154.88 / $154.88
| Professional | TC | $114.82 | $154.88 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $218.78 / $524.81
| Professional | | $131.83 | $218.78 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.02 / $54.95 / $117.49
| Professional | 26 | $38.02 | $54.95 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $165.96 / $346.74
| Professional | TC | $91.20 | $165.96 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $190.55 / $316.23
| Professional | | $165.96 | $190.55 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $47.86 / $79.43
| Professional | 26 | $40.74 | $47.86 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $144.54 / $245.47
| Professional | TC | $123.03 | $144.54 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $128.82
| Facility | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $190.55 / $398.11
| Professional | | $141.25 | $190.55 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $51.29 / $93.33
| Professional | 26 | $37.15 | $51.29 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $144.54 / $288.40
| Professional | TC | $100.00 | $144.54 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $213.80 / $257.04
| Professional | | $112.20 | $213.80 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $53.70 / $60.26
| Professional | 26 | $25.70 | $53.70 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $85.11 / $162.18 / $199.53
| Professional | TC | $85.11 | $162.18 | $199.53 |