- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $229.09 / $338.84
| Professional | | $151.36 | $229.09 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $41.69 / $87.10
| Professional | 26 | $32.36 | $41.69 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $128.82 / $177.83 / $309.03
| Professional | TC | $128.82 | $177.83 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $323.59 / $323.59
| Professional | | $263.03 | $323.59 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $67.61 / $67.61
| Professional | 26 | $53.70 | $67.61 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $257.04 / $257.04
| Professional | TC | $208.93 | $257.04 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $309.03 / $426.58
| Professional | | $194.98 | $309.03 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $58.88 / $85.11
| Professional | 26 | $33.11 | $58.88 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $245.47 / $338.84
| Professional | TC | $162.18 | $245.47 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $23.99 / $93.33 / $117.49
| Facility | | $23.99 | $93.33 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $389.05 / $794.33
| Professional | | $190.55 | $389.05 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $70.79 / $120.23
| Professional | 26 | $39.81 | $70.79 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $151.36 / $309.03 / $676.08
| Professional | TC | $151.36 | $309.03 | $676.08 |