- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $363.08 / $794.33
| Facility | | $131.83 | $363.08 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $23.99 / $61.66
| Facility | 26 | $22.91 | $23.99 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $134.90 / $338.84
| Professional | | $107.15 | $134.90 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.49 / $23.99 / $52.48
| Professional | 26 | $13.49 | $23.99 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $112.20 / $199.53
| Professional | TC | $95.50 | $112.20 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $194.98
| Facility | | $194.98 | $194.98 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $199.53 / $302.00
| Professional | | $120.23 | $199.53 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.88 / $21.38 / $45.71
| Professional | 26 | $12.88 | $21.38 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $190.55 / $269.15
| Professional | TC | $104.71 | $190.55 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $147.91
| Professional | | $144.54 | $144.54 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $169.82 / $269.15
| Professional | | $128.82 | $169.82 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.22 / $21.88 / $38.90
| Professional | 26 | $11.22 | $21.88 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $151.36 / $251.19
| Professional | TC | $109.65 | $151.36 | $251.19 |