- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $147.91
| Facility | | $147.91 | $147.91 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $19.05 / $19.05
| Facility | 26 | $19.05 | $19.05 | $19.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $93.33 / $154.88
| Professional | | $67.61 | $93.33 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.98 / $19.05 / $75.86
| Professional | 26 | $16.98 | $19.05 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $47.86 / $69.18 / $128.82
| Professional | TC | $47.86 | $69.18 | $128.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $977.24 / $977.24 / $1,174.90
| Facility | | $977.24 | $977.24 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $245.47
| Professional | | $134.90 | $134.90 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $37.15 / $66.07
| Professional | 26 | $37.15 | $37.15 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $97.72
| Professional | TC | $97.72 | $97.72 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $114.82 / $245.47
| Professional | | $91.20 | $114.82 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $25.12 / $42.66
| Professional | 26 | $19.05 | $25.12 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $66.07 / $95.50 / $154.88
| Professional | TC | $66.07 | $95.50 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $186.21 / $245.47
| Professional | | $89.13 | $186.21 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $25.70 / $66.07
| Professional | 26 | $21.88 | $25.70 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $162.18 / $162.18
| Professional | TC | $64.57 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $109.65 / $208.93
| Professional | | $67.61 | $109.65 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $26.92 / $45.71
| Professional | 26 | $20.42 | $26.92 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $58.88 / $95.50 / $128.82
| Professional | TC | $58.88 | $95.50 | $128.82 |