- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $302.00
| Facility | | $151.36 | $151.36 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $181.97 / $181.97 / $181.97
| Facility | TC | $181.97 | $181.97 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $158.49 / $524.81
| Professional | | $79.43 | $158.49 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $24.55 / $45.71 / $66.07
| Professional | 26 | $24.55 | $45.71 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $89.13 / $151.36
| Professional | TC | $61.66 | $89.13 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $51.29 / $70.79 / $309.03
| Professional | | $51.29 | $70.79 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $15.14 / $77.62
| Professional | 26 | $12.02 | $15.14 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $36.31 / $36.31 / $39.81
| Professional | TC | $36.31 | $36.31 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Professional | | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $89.13 / $169.82
| Professional | | $46.77 | $89.13 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.30 / $28.84 / $52.48
| Professional | 26 | $12.30 | $28.84 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.88 / $64.57 / $125.89
| Professional | TC | $33.88 | $64.57 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $107.15 / $169.82
| Professional | | $54.95 | $107.15 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.22 / $27.54 / $57.54
| Professional | 26 | $16.22 | $27.54 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $79.43 / $125.89
| Professional | TC | $38.90 | $79.43 | $125.89 |