- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $549.54 / $549.54
| Facility | | $109.65 | $549.54 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $25.12 / $25.12
| Facility | 26 | $25.12 | $25.12 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $141.25 / $281.84
| Professional | | $102.33 | $141.25 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $23.99 / $52.48
| Professional | 26 | $12.88 | $23.99 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $114.82 / $190.55
| Professional | TC | $95.50 | $114.82 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $181.97 / $309.03
| Professional | | $128.82 | $181.97 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.62 / $28.84 / $50.12
| Professional | 26 | $18.62 | $28.84 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $151.36 / $257.04
| Professional | TC | $107.15 | $151.36 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $194.98 / $346.74
| Professional | | $151.36 | $194.98 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.22 / $27.54 / $54.95
| Professional | 26 | $16.22 | $27.54 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $128.82 / $165.96 / $295.12
| Professional | TC | $128.82 | $165.96 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $281.84 / $457.09
| Professional | | $173.78 | $281.84 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.92 / $43.65 / $70.79
| Professional | 26 | $26.92 | $43.65 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $251.19 / $380.19
| Professional | TC | $147.91 | $251.19 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $154.88 / $309.03
| Professional | | $114.82 | $154.88 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $25.70 / $52.48
| Professional | 26 | $12.88 | $25.70 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $128.82 / $239.88
| Professional | TC | $97.72 | $128.82 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $218.78 / $416.87
| Professional | | $158.49 | $218.78 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $33.11 / $63.10
| Professional | 26 | $21.88 | $33.11 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $186.21 / $380.19
| Professional | TC | $131.83 | $186.21 | $380.19 |