- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $870.96 / $977.24
| Facility | | $79.43 | $870.96 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $1,122.02
| Facility | TC | $1,122.02 | $1,122.02 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $125.89 / $239.88
| Professional | | $44.67 | $125.89 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $38.02 / $52.48
| Professional | 26 | $19.95 | $38.02 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $114.82 / $199.53
| Professional | TC | $87.10 | $114.82 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $602.56 / $794.33 / $1,202.26
| Facility | | $602.56 | $794.33 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $194.98
| Professional | | $165.96 | $165.96 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $36.31 / $42.66
| Professional | 26 | $36.31 | $36.31 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $208.93
| Professional | TC | $177.83 | $177.83 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $269.15
| Facility | | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $208.93 / $436.52
| Professional | | $131.83 | $208.93 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $29.51 / $75.86
| Professional | 26 | $18.20 | $29.51 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $158.49 / $275.42
| Professional | TC | $109.65 | $158.49 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $125.89 / $436.52
| Professional | | $123.03 | $125.89 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $23.44 / $75.86
| Professional | 26 | $20.89 | $23.44 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $165.96
| Professional | TC | $102.33 | $102.33 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $208.93 / $302.00
| Professional | | $112.20 | $208.93 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $30.90 / $52.48
| Professional | 26 | $19.95 | $30.90 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $165.96 / $229.09
| Professional | TC | $91.20 | $165.96 | $229.09 |