- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $147.91
| Facility | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $79.43
| Facility | 26 | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $181.97 / $309.03
| Professional | | $138.04 | $181.97 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $89.13 / $169.82
| Professional | 26 | $53.70 | $89.13 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $93.33 / $208.93
| Professional | TC | $72.44 | $93.33 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $588.84 / $588.84
| Professional | | $380.19 | $588.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $208.93 / $323.59 / $323.59
| Professional | 26 | $208.93 | $323.59 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $269.15 / $269.15
| Professional | TC | $173.78 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $309.03 / $489.78
| Professional | | $208.93 | $309.03 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $109.65 / $194.98
| Professional | 26 | $72.44 | $109.65 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $186.21 / $302.00
| Professional | TC | $112.20 | $186.21 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $33.11 / $64.57 / $3,548.13
| Facility | | $33.11 | $64.57 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $331.13 / $741.31
| Professional | | $234.42 | $331.13 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $138.04 / $190.55
| Professional | 26 | $56.23 | $138.04 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $177.83 / $562.34
| Professional | TC | $123.03 | $177.83 | $562.34 |