- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $131.83
| Facility | | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.92 / $26.92 / $26.92
| Facility | 26 | $26.92 | $26.92 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $128.82 / $199.53
| Professional | | $104.71 | $128.82 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.18 / $22.91 / $37.15
| Professional | 26 | $13.18 | $22.91 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $83.18 / $104.71 / $165.96
| Professional | TC | $83.18 | $104.71 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $24.55 / $120.23 / $169.82
| Facility | | $24.55 | $120.23 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $26.92 / $26.92 / $26.92
| Professional | | $26.92 | $26.92 | $26.92 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $223.87
| Facility | | $204.17 | $204.17 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $5.62 / $26.30 / $37.15
| Facility | 26 | $5.62 | $26.30 | $37.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $181.97 / $645.65
| Professional | | $131.83 | $181.97 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.38 / $27.54 / $107.15
| Professional | 26 | $17.38 | $27.54 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $158.49 / $602.56
| Professional | TC | $109.65 | $158.49 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $173.78 / $302.00
| Professional | | $112.20 | $173.78 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.75 / $19.05 / $32.36
| Professional | 26 | $11.75 | $19.05 | $32.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $151.36 / $281.84
| Professional | TC | $91.20 | $151.36 | $281.84 |