- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $147.91
| Facility | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.92 / $26.92 / $26.92
| Facility | 26 | $26.92 | $26.92 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $131.83 / $199.53
| Professional | | $112.20 | $131.83 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $22.91 / $51.29
| Professional | 26 | $12.02 | $22.91 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $112.20 / $162.18
| Professional | TC | $95.50 | $112.20 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $125.89
| Professional | | $95.50 | $95.50 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $21.38 / $24.55
| Professional | 26 | $21.38 | $21.38 | $24.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $154.88 / $165.96
| Professional | | $128.82 | $154.88 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.49 / $23.99 / $26.30
| Professional | 26 | $15.49 | $23.99 | $26.30 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $128.82 / $138.04
| Professional | TC | $112.20 | $128.82 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $190.55 / $288.40
| Professional | | $125.89 | $190.55 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $22.91 / $39.81
| Professional | 26 | $12.88 | $22.91 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $165.96 / $269.15
| Professional | TC | $109.65 | $165.96 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.41 / $117.49 / $194.98
| Professional | | $1.41 | $117.49 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $0.20 / $13.49 / $33.11
| Professional | 26 | $0.20 | $13.49 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $1.20 / $102.33 / $158.49
| Professional | TC | $1.20 | $102.33 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1.41 / $1.41 / $194.98
| Professional | | $1.41 | $1.41 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $0.20 / $0.20 / $33.11
| Professional | 26 | $0.20 | $0.20 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $1.20 / $1.20 / $158.49
| Professional | TC | $1.20 | $1.20 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $257.04
| Professional | | $128.82 | $128.82 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $21.88 / $41.69
| Professional | 26 | $21.88 | $21.88 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $213.80
| Professional | TC | $107.15 | $107.15 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $181.97 / $281.84
| Professional | | $125.89 | $181.97 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.59 / $23.44 / $41.69
| Professional | 26 | $12.59 | $23.44 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $173.78 / $263.03
| Professional | TC | $114.82 | $173.78 | $263.03 |