- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $169.82
| Facility | | $169.82 | $169.82 | $169.82 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $77.62 / $77.62
| Facility | 26 | $77.62 | $77.62 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $151.36 / $354.81
| Professional | | $95.50 | $151.36 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $44.67 / $117.49 / $457.09
| Professional | 26 | $44.67 | $117.49 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $51.29 / $77.62 / $151.36
| Professional | TC | $51.29 | $77.62 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $75.86
| Professional | | $75.86 | $75.86 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Professional | 26 | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $181.97
| Professional | | $154.88 | $154.88 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $89.13
| Professional | 26 | $75.86 | $75.86 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $77.62 / $91.20
| Professional | TC | $77.62 | $77.62 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $79.43 / $218.78
| Professional | | $64.57 | $79.43 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $37.15 / $117.49
| Professional | 26 | $32.36 | $37.15 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $27.54 / $43.65 / $100.00
| Professional | TC | $27.54 | $43.65 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $104.71 / $173.78
| Professional | | $87.10 | $104.71 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $58.88 / $81.28
| Professional | 26 | $42.66 | $58.88 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $42.66 / $52.48 / $91.20
| Professional | TC | $42.66 | $52.48 | $91.20 |