- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $141.25
| Facility | | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $81.28
| Facility | 26 | $81.28 | $81.28 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $154.88 / $239.88
| Professional | | $102.33 | $154.88 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $79.43 / $151.36
| Professional | 26 | $51.29 | $79.43 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $54.95 / $72.44 / $181.97
| Professional | TC | $54.95 | $72.44 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $114.82 / $218.78
| Facility | | $72.44 | $114.82 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $141.25 / $323.59
| Professional | | $79.43 | $141.25 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $234.42 / $6,165.95
| Facility | | $218.78 | $234.42 | $6,165.95 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $93.33 / $131.83
| Facility | 26 | $19.95 | $93.33 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $323.59 / $2,344.23
| Professional | | $117.49 | $323.59 | $2,344.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $109.65 / $380.19
| Professional | 26 | $63.10 | $109.65 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $53.70 / $158.49 / $812.83
| Professional | TC | $53.70 | $158.49 | $812.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $15,135.61 / $15,135.61 / $17,378.01
| Facility | | $15,135.61 | $15,135.61 | $17,378.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $213.80
| Professional | 26 | $141.25 | $141.25 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $8,912.51 / $8,912.51 / $8,912.51
| Facility | | $8,912.51 | $8,912.51 | $8,912.51 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $269.15 / $724.44
| Professional | | $131.83 | $269.15 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $79.43 / $151.36
| Professional | 26 | $51.29 | $79.43 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $173.78 / $630.96
| Professional | TC | $60.26 | $173.78 | $630.96 |