- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $144.54
| Facility | | $144.54 | $144.54 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $213.80 / $870.96
| Professional | | $134.90 | $213.80 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $47.86 / $97.72
| Professional | 26 | $39.81 | $47.86 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $158.49 / $257.04
| Professional | TC | $87.10 | $158.49 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $251.19 / $389.05
| Professional | | $154.88 | $251.19 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $58.88 / $91.20
| Professional | 26 | $39.81 | $58.88 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $186.21 / $302.00
| Professional | TC | $114.82 | $186.21 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $309.03 / $380.19
| Professional | | $194.98 | $309.03 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $64.57 / $100.00
| Professional | 26 | $51.29 | $64.57 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $229.09 / $295.12
| Professional | TC | $141.25 | $229.09 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $229.09 / $331.13
| Professional | | $169.82 | $229.09 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $58.88 / $85.11
| Professional | 26 | $48.98 | $58.88 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $169.82 / $234.42
| Professional | TC | $125.89 | $169.82 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $208.93 / $467.74
| Professional | | $141.25 | $208.93 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $51.29 / $112.20
| Professional | 26 | $40.74 | $51.29 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $158.49 / $371.54
| Professional | TC | $97.72 | $158.49 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $223.87 / $389.05
| Professional | | $151.36 | $223.87 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $60.26 / $93.33
| Professional | 26 | $48.98 | $60.26 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $165.96 / $309.03
| Professional | TC | $95.50 | $165.96 | $309.03 |