- 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
- $162.18 / $162.18 / $162.18
| Facility | 26 | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $162.18
| Facility | TC | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $371.54 / $758.58
| Professional | | $323.59 | $371.54 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $151.36 / $181.97 / $371.54
| Professional | 26 | $151.36 | $181.97 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $154.88 / $218.78 / $446.68
| Professional | TC | $154.88 | $218.78 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $758.58
| Professional | | $173.78 | $173.78 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $74.13 / $173.78
| Professional | 26 | $74.13 | $74.13 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $323.59 / $380.19 / $380.19
| Professional | TC | $323.59 | $380.19 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $851.14 / $851.14
| Facility | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $186.21 / $269.15
| Facility | 26 | $39.81 | $186.21 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $44.67 / $208.93 / $302.00
| Facility | TC | $44.67 | $208.93 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $416.87 / $2,238.72
| Professional | | $331.13 | $416.87 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $812.83
| Professional | 26 | $154.88 | $154.88 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $223.87 / $912.01
| Professional | TC | $173.78 | $223.87 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $234.42 / $389.05
| Facility | | $158.49 | $234.42 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $524.81 / $741.31
| Professional | | $323.59 | $524.81 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $138.04 / $181.97 / $346.74
| Professional | 26 | $138.04 | $181.97 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $245.47 / $416.87
| Professional | TC | $141.25 | $245.47 | $416.87 |