- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $1,096.48
| Facility | | $223.87 | $223.87 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $158.49 / $309.03
| Professional | | $117.49 | $158.49 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $28.84 / $53.70
| Professional | 26 | $19.05 | $28.84 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $123.03 / $229.09
| Professional | TC | $95.50 | $123.03 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $257.04 / $257.04
| Professional | | $208.93 | $257.04 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $40.74 / $40.74
| Professional | 26 | $33.11 | $40.74 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $177.83 / $218.78 / $218.78
| Professional | TC | $177.83 | $218.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $251.19 / $380.19
| Professional | | $162.18 | $251.19 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $38.02 / $52.48
| Professional | 26 | $20.42 | $38.02 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $208.93 / $281.84
| Professional | TC | $144.54 | $208.93 | $281.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $15.14 / $77.62 / $93.33
| Facility | | $15.14 | $77.62 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $316.23 / $660.69
| Professional | | $158.49 | $316.23 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $43.65 / $72.44
| Professional | 26 | $23.44 | $43.65 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $257.04 / $602.56
| Professional | TC | $141.25 | $257.04 | $602.56 |