- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $138.04 / $138.04
| Facility | | $138.04 | $138.04 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $33.88 / $33.88
| Facility | 26 | $33.88 | $33.88 | $33.88 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $104.71
| Facility | TC | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $190.55 / $645.65
| Professional | | $70.79 | $190.55 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $87.10 / $331.13
| Professional | 26 | $21.88 | $87.10 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $53.70 / $81.28 / $190.55
| Professional | TC | $53.70 | $81.28 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $204.17
| Professional | | $117.49 | $117.49 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.30 / $26.30 / $45.71
| Professional | 26 | $26.30 | $26.30 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $158.49
| Professional | TC | $91.20 | $91.20 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $60.26 / $177.83
| Professional | | $43.65 | $60.26 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.48 / $16.98 / $46.77
| Professional | 26 | $11.48 | $16.98 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $32.36 / $43.65 / $138.04
| Professional | TC | $32.36 | $43.65 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $162.18
| Professional | | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $36.31 / $36.31
| Professional | 26 | $36.31 | $36.31 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $125.89
| Professional | TC | $125.89 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $114.82 / $181.97
| Professional | | $102.33 | $114.82 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $24.55 / $25.70 / $45.71
| Professional | 26 | $24.55 | $25.70 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $89.13 / $138.04
| Professional | TC | $77.62 | $89.13 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $134.90 / $229.09
| Professional | | $58.88 | $134.90 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.49 / $43.65 / $64.57
| Professional | 26 | $15.49 | $43.65 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $42.66 / $89.13 / $158.49
| Professional | TC | $42.66 | $89.13 | $158.49 |