- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $269.15 / $5,623.41
| Facility | | $151.36 | $269.15 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $263.03 / $346.74
| Professional | | $77.62 | $263.03 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $44.67 / $288.40
| Professional | 26 | $25.12 | $44.67 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $77.62 / $204.17
| Professional | TC | $50.12 | $77.62 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $288.40 / $288.40
| Professional | | $257.04 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $87.10 / $87.10
| Professional | 26 | $75.86 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $177.83 / $204.17 / $204.17
| Professional | TC | $177.83 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $186.21
| Professional | | $147.91 | $147.91 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $43.65 / $43.65 / $54.95
| Professional | 26 | $43.65 | $43.65 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $131.83
| Professional | TC | $104.71 | $104.71 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $77.62 / $114.82
| Facility | | $61.66 | $77.62 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $245.47 / $281.84
| Professional | | $117.49 | $245.47 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $85.11 / $87.10
| Professional | 26 | $67.61 | $85.11 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $154.88 / $426.58
| Professional | TC | $123.03 | $154.88 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $223.87 / $302.00
| Professional | | $109.65 | $223.87 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $69.18 / $89.13
| Professional | 26 | $37.15 | $69.18 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $147.91 / $208.93
| Professional | TC | $72.44 | $147.91 | $208.93 |