- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $933.25 / $933.25 / $933.25
| Facility | | $933.25 | $933.25 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $138.04 / $263.03
| Professional | | $104.71 | $138.04 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $22.91 / $51.29
| Professional | 26 | $14.13 | $22.91 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $112.20 / $194.98
| Professional | TC | $95.50 | $112.20 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $134.90 / $251.19
| Professional | | $107.15 | $134.90 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $23.44 / $41.69
| Professional | 26 | $19.50 | $23.44 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $165.96
| Professional | TC | $100.00 | $100.00 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $213.80 / $346.74
| Professional | | $141.25 | $213.80 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.80 / $26.30 / $50.12
| Professional | 26 | $13.80 | $26.30 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $117.49 / $190.55 / $302.00
| Professional | TC | $117.49 | $190.55 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $223.87 / $354.81
| Facility | | $117.49 | $223.87 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $37.15 / $37.15
| Facility | 26 | $37.15 | $37.15 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $190.55 / $323.59
| Professional | | $138.04 | $190.55 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $25.70 / $51.29
| Professional | 26 | $14.79 | $25.70 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $120.23 / $169.82 / $295.12
| Professional | TC | $120.23 | $169.82 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $851.14 / $851.14
| Facility | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $144.54
| Facility | 26 | $144.54 | $144.54 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $1,122.02 / $1,122.02 / $1,230.27
| Professional | | $1,122.02 | $1,122.02 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Professional | 26 | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $933.25 / $933.25 / $1,148.15
| Professional | TC | $933.25 | $933.25 | $1,148.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $10.96 / $154.88 / $165.96
| Facility | | $10.96 | $154.88 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $181.97 / $295.12
| Professional | | $128.82 | $181.97 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $24.55 / $42.66
| Professional | 26 | $12.88 | $24.55 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $158.49 / $263.03
| Professional | TC | $109.65 | $158.49 | $263.03 |