- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $263.03 / $831.76
| Professional | | $138.04 | $263.03 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $81.28 / $208.93
| Professional | 26 | $38.90 | $81.28 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $190.55 / $331.13
| Professional | TC | $97.72 | $190.55 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $208.93 / $208.93
| Professional | | $63.10 | $208.93 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $77.62
| Facility | 26 | $63.10 | $63.10 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $245.47 / $457.09
| Professional | | $181.97 | $245.47 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $63.10 / $112.20
| Professional | 26 | $33.11 | $63.10 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $165.96 / $302.00
| Professional | TC | $95.50 | $165.96 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $229.09 / $354.81
| Professional | | $223.87 | $229.09 | $354.81 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $77.62
| Facility | 26 | $63.10 | $63.10 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $295.12 / $354.81
| Professional | | $186.21 | $295.12 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $41.69 / $63.10 / $95.50
| Professional | 26 | $41.69 | $63.10 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $147.91 / $218.78
| Professional | TC | $97.72 | $147.91 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $213.80 / $371.54
| Professional | | $120.23 | $213.80 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $50.12 / $97.72
| Professional | 26 | $37.15 | $50.12 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $83.18 / $147.91 / $257.04
| Professional | TC | $83.18 | $147.91 | $257.04 |