- Facility/Professional
- Facility
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Facility | TC | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $114.82 / $190.55
| Professional | | $74.13 | $114.82 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $107.15 / $117.49
| Professional | 26 | $57.54 | $107.15 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $43.65 / $70.79
| Professional | TC | $28.84 | $43.65 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $281.84 / $281.84
| Professional | | $281.84 | $281.84 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $38.90 / $177.83
| Professional | 26 | $34.67 | $38.90 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $18.62 / $18.62 / $18.62
| Professional | TC | $18.62 | $18.62 | $18.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Professional | | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $45.71 / $87.10 / $165.96
| Professional | | $45.71 | $87.10 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $67.61 / $123.03
| Professional | 26 | $28.84 | $67.61 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $14.79 / $28.18 / $53.70
| Professional | TC | $14.79 | $28.18 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $100.00 / $165.96
| Professional | | $56.23 | $100.00 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $64.57 / $125.89
| Professional | 26 | $37.15 | $64.57 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $17.78 / $34.67 / $57.54
| Professional | TC | $17.78 | $34.67 | $57.54 |