- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Facility | | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.90 / $58.88 / $120.23
| Professional | | $38.90 | $58.88 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $37.15 / $70.79
| Professional | 26 | $20.89 | $37.15 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- 50
- Typical Low / Median / Typical High
- $51.29 / $51.29 / $190.55
| Professional | 50 | $51.29 | $51.29 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.14 / $21.38 / $67.61
| Professional | TC | $15.14 | $21.38 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $83.18 / $83.18
| Professional | | $67.61 | $83.18 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $52.48 / $52.48
| Professional | 26 | $42.66 | $52.48 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.12 / $30.90 / $30.90
| Professional | TC | $25.12 | $30.90 | $30.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $128.82 / $181.97
| Professional | | $66.07 | $128.82 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $47.86 / $67.61
| Professional | 26 | $28.18 | $47.86 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.91 / $77.62 / $117.49
| Professional | TC | $22.91 | $77.62 | $117.49 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $19.05 / $35.48 / $54.95
| Facility | | $19.05 | $35.48 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $128.82 / $269.15
| Professional | | $89.13 | $128.82 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $58.88 / $95.50
| Professional | 26 | $32.36 | $58.88 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $46.77 / $79.43 / $169.82
| Professional | TC | $46.77 | $79.43 | $169.82 |