- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $346.74 / $346.74
| Facility | | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $63.10
| Facility | 26 | $63.10 | $63.10 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $151.36 / $549.54
| Professional | | $93.33 | $151.36 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $28.84 / $87.10
| Professional | 26 | $20.89 | $28.84 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $109.65 / $234.42
| Professional | TC | $87.10 | $109.65 | $234.42 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $251.19 / $389.05
| Facility | | $213.80 | $251.19 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $144.54 / $309.03
| Professional | | $109.65 | $144.54 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.95 / $28.18 / $41.69
| Professional | 26 | $19.95 | $28.18 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $83.18 / $117.49 / $158.49
| Professional | TC | $83.18 | $117.49 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $478.63 / $575.44
| Facility | | $323.59 | $478.63 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $162.18 / $275.42
| Professional | | $123.03 | $162.18 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $28.84 / $51.29
| Professional | 26 | $22.91 | $28.84 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $134.90 / $269.15
| Professional | TC | $97.72 | $134.90 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $218.78
| Facility | | $218.78 | $218.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $147.91 / $229.09
| Professional | | $112.20 | $147.91 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $27.54 / $41.69
| Professional | 26 | $22.91 | $27.54 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $123.03 / $186.21
| Professional | TC | $91.20 | $123.03 | $186.21 |