- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $323.59
| Facility | | $323.59 | $323.59 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $32.36 / $32.36
| Facility | 26 | $32.36 | $32.36 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $138.04 / $331.13
| Professional | | $102.33 | $138.04 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.79 / $23.99 / $53.70
| Professional | 26 | $14.79 | $23.99 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $114.82 / $190.55
| Professional | TC | $91.20 | $114.82 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $100.00 / $134.90
| Professional | | $93.33 | $100.00 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $19.50 / $25.70
| Professional | 26 | $19.50 | $19.50 | $25.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $154.88 / $190.55
| Professional | | $131.83 | $154.88 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $29.51 / $32.36
| Professional | 26 | $25.12 | $29.51 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $125.89 / $151.36
| Professional | TC | $107.15 | $125.89 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $138.04
| Facility | | $134.90 | $134.90 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $33.11 / $33.11
| Professional | 26 | $21.88 | $33.11 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $275.42 / $275.42
| Facility | | $275.42 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $181.97 / $346.74
| Professional | | $131.83 | $181.97 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.22 / $26.92 / $60.26
| Professional | 26 | $16.22 | $26.92 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $151.36 / $309.03
| Professional | TC | $109.65 | $151.36 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $158.49 / $257.04
| Professional | | $123.03 | $158.49 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.59 / $23.44 / $38.02
| Professional | 26 | $12.59 | $23.44 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $131.83 / $229.09
| Professional | TC | $102.33 | $131.83 | $229.09 |