- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Facility | | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Facility | TC | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $169.82 / $602.56
| Professional | | $69.18 | $169.82 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $54.95 / $288.40
| Professional | 26 | $23.44 | $54.95 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $81.28 / $134.90
| Professional | TC | $52.48 | $81.28 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $50.12 / $50.12
| Professional | | $50.12 | $50.12 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.49 / $15.49 / $23.99
| Professional | 26 | $15.49 | $15.49 | $23.99 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $74.13 / $74.13
| Professional | TC | $74.13 | $74.13 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $100.00 / $190.55
| Professional | | $37.15 | $100.00 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.22 / $38.02 / $52.48
| Professional | 26 | $11.22 | $38.02 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.92 / $66.07 / $138.04
| Professional | TC | $26.92 | $66.07 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $114.82 / $177.83
| Professional | | $100.00 | $114.82 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $31.62 / $50.12
| Professional | 26 | $23.99 | $31.62 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $81.28 / $134.90
| Professional | TC | $74.13 | $81.28 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $44.67 / $56.23 / $194.98
| Professional | | $44.67 | $56.23 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.30 / $16.60 / $75.86
| Professional | 26 | $12.30 | $16.60 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $32.36 / $42.66 / $131.83
| Professional | TC | $32.36 | $42.66 | $131.83 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $109.65 / $245.47
| Facility | | $72.44 | $109.65 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $117.49
| Facility | 26 | $117.49 | $117.49 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $389.05 / $389.05 / $389.05
| Facility | TC | $389.05 | $389.05 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $134.90 / $707.95
| Professional | | $64.57 | $134.90 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.60 / $33.88 / $162.18
| Professional | 26 | $16.60 | $33.88 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $47.86 / $102.33 / $549.54
| Professional | TC | $47.86 | $102.33 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $12.59 / $41.69 / $53.70
| Facility | | $12.59 | $41.69 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $104.71 / $213.80
| Professional | | $64.57 | $104.71 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.60 / $27.54 / $56.23
| Professional | 26 | $16.60 | $27.54 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $47.86 / $77.62 / $154.88
| Professional | TC | $47.86 | $77.62 | $154.88 |