- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $616.60 / $616.60
| Facility | | $102.33 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $138.04 / $295.12
| Professional | | $109.65 | $138.04 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $25.12 / $63.10
| Professional | 26 | $20.89 | $25.12 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $85.11 / $104.71 / $186.21
| Professional | TC | $85.11 | $104.71 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $147.91 / $257.04
| Professional | | $104.71 | $147.91 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $28.84 / $48.98
| Professional | 26 | $21.38 | $28.84 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $117.49 / $208.93
| Professional | TC | $87.10 | $117.49 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $186.21 / $281.84
| Professional | | $131.83 | $186.21 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $30.90 / $54.95
| Professional | 26 | $22.91 | $30.90 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $147.91 / $229.09
| Professional | TC | $93.33 | $147.91 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $181.97 / $331.13
| Professional | | $138.04 | $181.97 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.92 / $36.31 / $66.07
| Professional | 26 | $26.92 | $36.31 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $147.91 / $269.15
| Professional | TC | $112.20 | $147.91 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $144.54 / $281.84
| Professional | | $112.20 | $144.54 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $28.84 / $52.48
| Professional | 26 | $20.89 | $28.84 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $114.82 / $223.87
| Professional | TC | $91.20 | $114.82 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $181.97 / $331.13
| Professional | | $117.49 | $181.97 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $36.31 / $67.61
| Professional | 26 | $23.99 | $36.31 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $141.25 / $251.19
| Professional | TC | $97.72 | $141.25 | $251.19 |