- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $891.25 / $1,318.26
| Facility | | $891.25 | $891.25 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $134.90 / $245.47
| Professional | | $95.50 | $134.90 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $57.54 / $83.18
| Professional | 26 | $30.20 | $57.54 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $100.00 / $186.21
| Professional | TC | $64.57 | $100.00 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $707.95 / $776.25 / $1,122.02
| Facility | | $707.95 | $776.25 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $234.42
| Facility | 26 | $234.42 | $234.42 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $181.97
| Professional | | $154.88 | $154.88 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $52.48 / $61.66
| Professional | 26 | $52.48 | $52.48 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $125.89
| Professional | TC | $104.71 | $104.71 | $125.89 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $1,122.02 / $1,122.02
| Facility | | $269.15 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $169.82 / $501.19
| Professional | | $151.36 | $169.82 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $54.95 / $158.49
| Professional | 26 | $30.20 | $54.95 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $114.82 / $239.88
| Professional | TC | $100.00 | $114.82 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $125.89 / $501.19
| Professional | | $120.23 | $125.89 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $42.66 / $162.18
| Professional | 26 | $38.90 | $42.66 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $83.18 / $102.33
| Professional | TC | $81.28 | $83.18 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $154.88 / $302.00
| Professional | | $123.03 | $154.88 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $51.29 / $100.00
| Professional | 26 | $40.74 | $51.29 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $83.18 / $100.00 / $204.17
| Professional | TC | $83.18 | $100.00 | $204.17 |