- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $134.90
| Facility | | $134.90 | $134.90 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $25.12 / $25.12
| Facility | 26 | $25.12 | $25.12 | $25.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $128.82 / $389.05
| Professional | | $100.00 | $128.82 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $25.12 / $70.79
| Professional | 26 | $20.89 | $25.12 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $107.15 / $208.93
| Professional | TC | $87.10 | $107.15 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $257.04 / $436.52
| Facility | | $125.89 | $257.04 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $181.97 / $251.19
| Professional | | $131.83 | $181.97 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $31.62 / $48.98
| Professional | 26 | $23.99 | $31.62 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $147.91 / $199.53
| Professional | TC | $107.15 | $147.91 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $85.11
| Professional | | $32.36 | $33.11 | $85.11 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $208.93 / $316.23
| Facility | | $151.36 | $208.93 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $199.53
| Facility | 26 | $199.53 | $199.53 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $169.82 / $223.87
| Professional | | $134.90 | $169.82 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.30 / $31.62 / $39.81
| Professional | 26 | $26.30 | $31.62 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $138.04 / $186.21
| Professional | TC | $107.15 | $138.04 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $204.17 / $295.12
| Professional | | $109.65 | $204.17 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.39 / $42.66 / $63.10
| Professional | 26 | $22.39 | $42.66 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $162.18 / $223.87
| Professional | TC | $87.10 | $162.18 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $123.03 / $190.55
| Professional | | $30.90 | $123.03 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $147.91 / $251.19
| Professional | | $107.15 | $147.91 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $26.30 / $42.66
| Professional | 26 | $20.89 | $26.30 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $85.11 / $120.23 / $208.93
| Professional | TC | $85.11 | $120.23 | $208.93 |