- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $549.54
| Facility | | $251.19 | $251.19 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $112.20 / $380.19
| Professional | | $87.10 | $112.20 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $8.13 / $44.67 / $660.69
| Professional | 26 | $8.13 | $44.67 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $63.10 / $169.82
| Professional | TC | $50.12 | $63.10 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $309.03 / $309.03
| Professional | | $269.15 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $102.33 / $102.33
| Professional | 26 | $91.20 | $102.33 | $102.33 |
- 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
- $158.49 / $158.49 / $194.98
| Professional | | $158.49 | $158.49 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $52.48 / $66.07
| Professional | 26 | $52.48 | $52.48 | $66.07 |
- 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
- $74.13 / $91.20 / $134.90
| Facility | | $74.13 | $91.20 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $281.84 / $758.58
| Professional | | $186.21 | $281.84 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $100.00 / $114.82
| Professional | 26 | $91.20 | $100.00 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $173.78 / $512.86
| Professional | TC | $169.82 | $173.78 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $251.19 / $316.23
| Professional | | $128.82 | $251.19 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $44.67 / $83.18 / $104.71
| Professional | 26 | $44.67 | $83.18 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $85.11 / $165.96 / $213.80
| Professional | TC | $85.11 | $165.96 | $213.80 |