- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $398.11 / $398.11
| Facility | | $177.83 | $398.11 | $398.11 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $35.48 / $35.48 / $35.48
| Facility | 26 | $35.48 | $35.48 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $125.89 / $204.17
| Professional | | $104.71 | $125.89 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $22.91 / $41.69
| Professional | 26 | $12.02 | $22.91 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $104.71 / $151.36
| Professional | TC | $87.10 | $104.71 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $147.91 / $181.97
| Professional | | $93.33 | $147.91 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $208.93 / $281.84
| Facility | | $194.98 | $208.93 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $23.44 / $77.62 / $194.98
| Professional | | $23.44 | $77.62 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $91.20
| Facility | | $91.20 | $91.20 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $190.55 / $288.40
| Professional | | $141.25 | $190.55 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $22.91 / $35.48
| Professional | 26 | $14.13 | $22.91 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $120.23 / $173.78 / $269.15
| Professional | TC | $120.23 | $173.78 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $144.54 / $275.42
| Facility | | $107.15 | $144.54 | $275.42 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $52.48 / $102.33
| Facility | 26 | $52.48 | $52.48 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $181.97 / $1,202.26
| Professional | | $125.89 | $181.97 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $25.70 / $199.53
| Professional | 26 | $15.85 | $25.70 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $173.78 / $1,122.02
| Professional | TC | $112.20 | $173.78 | $1,122.02 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $12.59 / $181.97 / $257.04
| Facility | | $12.59 | $181.97 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $165.96 / $275.42
| Professional | | $123.03 | $165.96 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $23.99 / $35.48
| Professional | 26 | $14.13 | $23.99 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $138.04 / $245.47
| Professional | TC | $102.33 | $138.04 | $245.47 |