- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $302.00 / $354.81
| Professional | | $295.12 | $302.00 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $144.54 / $165.96 / $371.54
| Professional | 26 | $144.54 | $165.96 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $151.36 / $177.83
| Professional | TC | $147.91 | $151.36 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $575.44
| Professional | | $269.15 | $269.15 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $575.44 / $575.44
| Professional | | $575.44 | $575.44 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $269.15
| Professional | 26 | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $302.00 / $302.00 / $302.00
| Professional | TC | $302.00 | $302.00 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $630.96 / $794.33
| Facility | | $467.74 | $630.96 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $630.96 / $794.33
| Professional | | $467.74 | $630.96 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $776.25 / $776.25 / $812.83
| Facility | | $776.25 | $776.25 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $501.19 / $831.76
| Professional | | $338.84 | $501.19 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $165.96 / $251.19 / $398.11
| Professional | 26 | $165.96 | $251.19 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $251.19 / $446.68
| Professional | TC | $169.82 | $251.19 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $323.59 / $602.56
| Professional | | $208.93 | $323.59 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $112.20 / $302.00
| Professional | 26 | $95.50 | $112.20 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $162.18 / $281.84
| Professional | TC | $97.72 | $162.18 | $281.84 |