- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $128.82
| Facility | | $128.82 | $128.82 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $20.89 / $20.89
| Facility | 26 | $20.89 | $20.89 | $20.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $141.25 / $346.74
| Professional | | $102.33 | $141.25 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $25.12 / $52.48
| Professional | 26 | $19.05 | $25.12 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $117.49 / $177.83
| Professional | TC | $87.10 | $117.49 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $21.38 / $134.90 / $208.93
| Professional | | $21.38 | $134.90 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.80 / $19.50 / $33.11
| Professional | 26 | $13.80 | $19.50 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $128.82 / $169.82
| Professional | TC | $114.82 | $128.82 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $891.25 / $1,288.25 / $1,288.25
| Facility | | $891.25 | $1,288.25 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $213.80 / $537.03
| Professional | | $134.90 | $213.80 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $22.91 / $72.44
| Professional | 26 | $14.79 | $22.91 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $204.17 / $501.19
| Professional | TC | $112.20 | $204.17 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $169.82 / $331.13
| Professional | | $158.49 | $169.82 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $23.99 / $47.86
| Professional | 26 | $22.91 | $23.99 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $144.54 / $281.84
| Professional | TC | $138.04 | $144.54 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19.95 / $114.82 / $134.90
| Facility | | $19.95 | $114.82 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $186.21 / $380.19
| Professional | | $125.89 | $186.21 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $10.72 / $22.91 / $48.98
| Professional | 26 | $10.72 | $22.91 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $162.18 / $338.84
| Professional | TC | $107.15 | $162.18 | $338.84 |