- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Facility | | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $63.10 / $223.87
| Professional | | $46.77 | $63.10 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $41.69 / $107.15
| Professional | 26 | $19.95 | $41.69 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.70 / $38.02 / $134.90
| Professional | TC | $25.70 | $38.02 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $173.78 / $173.78
| Professional | | $154.88 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $69.18 / $69.18
| Professional | 26 | $60.26 | $69.18 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $104.71 / $107.15
| Professional | TC | $93.33 | $104.71 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $104.71
| Professional | | $85.11 | $85.11 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $33.11 / $41.69
| Professional | 26 | $33.11 | $33.11 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $51.29 / $51.29 / $64.57
| Professional | TC | $51.29 | $51.29 | $64.57 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $41.69 / $51.29 / $89.13
| Facility | | $41.69 | $51.29 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $141.25 / $645.65
| Professional | | $138.04 | $141.25 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $66.07 / $190.55
| Professional | 26 | $54.95 | $66.07 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $87.10 / $309.03
| Professional | TC | $79.43 | $87.10 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $141.25 / $177.83
| Professional | | $69.18 | $141.25 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $29.51 / $54.95 / $69.18
| Professional | 26 | $29.51 | $54.95 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $40.74 / $83.18 / $109.65
| Professional | TC | $40.74 | $83.18 | $109.65 |