- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $363.08 / $1,174.90
| Professional | | $199.53 | $363.08 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $107.15 / $151.36
| Professional | 26 | $61.66 | $107.15 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $218.78 / $426.58
| Professional | TC | $138.04 | $218.78 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $295.12
| Professional | | $93.33 | $93.33 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $114.82
| Facility | 26 | $93.33 | $93.33 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $363.08 / $575.44
| Professional | | $269.15 | $363.08 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $41.69 / $93.33 / $165.96
| Professional | 26 | $41.69 | $93.33 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $251.19 / $467.74
| Professional | TC | $134.90 | $251.19 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $338.84 / $588.84
| Professional | | $323.59 | $338.84 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $114.82
| Facility | 26 | $93.33 | $93.33 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $426.58 / $512.86
| Professional | | $275.42 | $426.58 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $93.33 / $138.04
| Professional | 26 | $63.10 | $93.33 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $213.80 / $309.03
| Professional | TC | $138.04 | $213.80 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $309.03 / $446.68
| Professional | | $173.78 | $309.03 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $63.10 / $138.04
| Professional | 26 | $54.95 | $63.10 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $120.23 / $213.80 / $363.08
| Professional | TC | $120.23 | $213.80 | $363.08 |