- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $181.97 / $398.11
| Professional | | $147.91 | $181.97 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $72.44 / $138.04
| Professional | 26 | $40.74 | $72.44 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $134.90 / $223.87
| Professional | TC | $107.15 | $134.90 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $323.59 / $457.09
| Facility | | $275.42 | $323.59 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $141.25 / $245.47
| Professional | | $107.15 | $141.25 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $29.51 / $41.69 / $70.79
| Professional | 26 | $29.51 | $41.69 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $69.18 / $100.00 / $162.18
| Professional | TC | $69.18 | $100.00 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $549.54 / $549.54
| Facility | | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $208.93 / $346.74
| Professional | | $162.18 | $208.93 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $41.69 / $58.88 / $93.33
| Professional | 26 | $41.69 | $58.88 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $120.23 / $147.91 / $263.03
| Professional | TC | $120.23 | $147.91 | $263.03 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $446.68 / $446.68
| Facility | | $446.68 | $446.68 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $239.88 / $354.81
| Professional | | $158.49 | $239.88 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $64.57 / $85.11
| Professional | 26 | $42.66 | $64.57 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $120.23 / $173.78 / $257.04
| Professional | TC | $120.23 | $173.78 | $257.04 |