- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $426.58 / $645.65
| Facility | | $131.83 | $426.58 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $141.25 / $141.25 / $141.25
| Facility | 26 | $141.25 | $141.25 | $141.25 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $251.19 / $389.05 / $977.24
| Facility | TC | $251.19 | $389.05 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $112.20 / $354.81
| Professional | | $70.79 | $112.20 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $56.23 / $144.54
| Professional | 26 | $22.91 | $56.23 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $48.98 / $79.43 / $213.80
| Professional | TC | $48.98 | $79.43 | $213.80 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $251.19 / $354.81
| Facility | | $213.80 | $251.19 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $109.65 / $229.09
| Professional | | $81.28 | $109.65 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $34.67 / $57.54
| Professional | 26 | $23.99 | $34.67 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $74.13 / $100.00
| Professional | TC | $52.48 | $74.13 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $309.03 / $575.44
| Facility | | $79.43 | $309.03 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $125.89 / $223.87
| Professional | | $83.18 | $125.89 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.30 / $39.81 / $61.66
| Professional | 26 | $26.30 | $39.81 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $56.23 / $87.10 / $165.96
| Professional | TC | $56.23 | $87.10 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $218.78
| Facility | | $218.78 | $218.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $102.33 / $165.96
| Professional | | $77.62 | $102.33 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.30 / $33.11 / $53.70
| Professional | 26 | $26.30 | $33.11 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $54.95 / $70.79 / $114.82
| Professional | TC | $54.95 | $70.79 | $114.82 |