- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $223.87 / $446.68
| Professional | | $128.82 | $223.87 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $43.65 / $75.86 / $147.91
| Professional | 26 | $43.65 | $75.86 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $89.13 / $154.88 / $257.04
| Professional | TC | $89.13 | $154.88 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $239.88
| Professional | | $75.86 | $75.86 | $239.88 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $93.33
| Facility | 26 | $75.86 | $75.86 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $239.88 / $371.54
| Professional | | $114.82 | $239.88 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $57.54 / $114.82
| Professional | 26 | $33.11 | $57.54 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $165.96 / $281.84
| Professional | TC | $79.43 | $165.96 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $263.03 / $436.52
| Professional | | $245.47 | $263.03 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $75.86 / $93.33
| Facility | 26 | $75.86 | $75.86 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $338.84 / $426.58
| Professional | | $213.80 | $338.84 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $46.77 / $67.61 / $112.20
| Professional | 26 | $46.77 | $67.61 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $169.82 / $251.19
| Professional | TC | $104.71 | $169.82 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $154.88 / $275.42
| Professional | | $134.90 | $154.88 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $52.48 / $93.33
| Professional | 26 | $34.67 | $52.48 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $109.65 / $199.53
| Professional | TC | $104.71 | $109.65 | $199.53 |