- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $398.11 / $891.25
| Facility | | $169.82 | $398.11 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $97.72
| Facility | 26 | $97.72 | $97.72 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $39.81 / $74.13 / $229.09
| Professional | | $39.81 | $74.13 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $40.74 / $97.72
| Professional | 26 | $33.11 | $40.74 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.12 / $30.90 / $134.90
| Professional | TC | $25.12 | $30.90 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $186.21 / $275.42
| Professional | | $58.88 | $186.21 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $77.62 / $134.90
| Professional | 26 | $33.11 | $77.62 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.70 / $141.25 / $208.93
| Professional | TC | $25.70 | $141.25 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $891.25
| Facility | | $331.13 | $331.13 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $37.15 / $37.15
| Professional | 26 | $37.15 | $37.15 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $28.18 / $28.18
| Professional | TC | $28.18 | $28.18 | $28.18 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $501.19 / $501.19
| Facility | | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $154.88 / $309.03
| Professional | | $60.26 | $154.88 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $69.18 / $109.65
| Professional | 26 | $33.88 | $69.18 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.12 / $66.07 / $199.53
| Professional | TC | $25.12 | $66.07 | $199.53 |