- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $100.00 / $177.83
| Professional | | $66.07 | $100.00 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.13 / $18.20 / $35.48
| Professional | 26 | $14.13 | $18.20 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $83.18 / $181.97
| Professional | TC | $50.12 | $83.18 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $104.71 / $208.93
| Professional | | $69.18 | $104.71 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $14.45 / $23.44 / $39.81
| Professional | 26 | $14.45 | $23.44 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $83.18 / $165.96
| Professional | TC | $50.12 | $83.18 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $162.18 / $194.98
| Professional | | $117.49 | $162.18 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.62 / $25.70 / $30.20
| Professional | 26 | $18.62 | $25.70 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $134.90 / $162.18
| Professional | TC | $97.72 | $134.90 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $112.20 / $208.93
| Professional | | $95.50 | $112.20 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.49 / $18.20 / $36.31
| Professional | 26 | $15.49 | $18.20 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $93.33 / $165.96
| Professional | TC | $79.43 | $93.33 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $114.82 / $204.17
| Professional | | $63.10 | $114.82 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.80 / $20.89 / $34.67
| Professional | 26 | $13.80 | $20.89 | $34.67 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $54.95 / $95.50 / $169.82
| Professional | TC | $54.95 | $95.50 | $169.82 |