- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Facility | | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.14 / $15.14 / $15.14
| Facility | 26 | $15.14 | $15.14 | $15.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $134.90 / $338.84
| Professional | | $107.15 | $134.90 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $11.75 / $22.91 / $54.95
| Professional | 26 | $11.75 | $22.91 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $112.20 / $186.21
| Professional | TC | $95.50 | $112.20 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $223.87 / $302.00
| Professional | | $151.36 | $223.87 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.60 / $25.70 / $43.65
| Professional | 26 | $16.60 | $25.70 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $190.55 / $269.15
| Professional | TC | $125.89 | $190.55 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $104.71
| Professional | | $32.36 | $33.11 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $208.93 / $295.12
| Professional | | $158.49 | $208.93 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $29.51 / $41.69
| Professional | 26 | $20.89 | $29.51 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $177.83 / $275.42
| Professional | TC | $134.90 | $177.83 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $257.04 / $354.81
| Professional | | $123.03 | $257.04 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $41.69 / $57.54
| Professional | 26 | $20.89 | $41.69 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $213.80 / $316.23
| Professional | TC | $100.00 | $213.80 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $30.90 / $181.97 / $239.88
| Professional | | $30.90 | $181.97 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $186.21 / $288.40
| Professional | | $134.90 | $186.21 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.18 / $23.99 / $40.74
| Professional | 26 | $13.18 | $23.99 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $162.18 / $251.19
| Professional | TC | $114.82 | $162.18 | $251.19 |