- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $208.93
| Facility | | $208.93 | $208.93 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $162.18 / $426.58
| Professional | | $123.03 | $162.18 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $77.62 / $363.08
| Professional | 26 | $54.95 | $77.62 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $77.62 / $194.98
| Professional | TC | $57.54 | $77.62 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $77.62 / $141.25
| Professional | | $77.62 | $77.62 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $31.62 / $70.79 / $107.15
| Professional | 26 | $31.62 | $70.79 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $208.93
| Professional | | $208.93 | $208.93 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $151.36 / $316.23
| Professional | | $72.44 | $151.36 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $70.79 / $134.90
| Professional | 26 | $33.88 | $70.79 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $36.31 / $75.86 / $177.83
| Professional | TC | $36.31 | $75.86 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $151.36 / $213.80
| Facility | | $107.15 | $151.36 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $204.17 / $1,949.84
| Professional | | $95.50 | $204.17 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $44.67 / $95.50 / $436.52
| Professional | 26 | $44.67 | $95.50 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $107.15 / $562.34
| Professional | TC | $50.12 | $107.15 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $42.66 / $66.07 / $107.15
| Facility | | $42.66 | $66.07 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $151.36 / $218.78
| Professional | | $95.50 | $151.36 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $44.67 / $74.13 / $104.71
| Professional | 26 | $44.67 | $74.13 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $79.43 / $117.49
| Professional | TC | $50.12 | $79.43 | $117.49 |