- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $43.65 / $69.18 / $147.91
| Professional | | $43.65 | $69.18 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $43.65 / $60.26
| Professional | 26 | $20.89 | $43.65 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $22.91 / $37.15 / $95.50
| Professional | TC | $22.91 | $37.15 | $95.50 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $173.78
| Facility | 26 | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $95.50 / $95.50
| Professional | | $79.43 | $95.50 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $43.65 / $43.65
| Professional | 26 | $37.15 | $43.65 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $40.74 / $47.86 / $47.86
| Professional | TC | $40.74 | $47.86 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $109.65 / $251.19
| Professional | | $79.43 | $109.65 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $39.81 / $114.82
| Professional | 26 | $21.38 | $39.81 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $39.81 / $56.23 / $123.03
| Professional | TC | $39.81 | $56.23 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $60.26 / $61.66 / $251.19
| Professional | | $60.26 | $61.66 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $27.54 / $30.20 / $114.82
| Professional | 26 | $27.54 | $30.20 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.20 / $33.88 / $39.81
| Professional | TC | $30.20 | $33.88 | $39.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $102.33 / $165.96
| Professional | | $58.88 | $102.33 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $35.48 / $70.79
| Professional | 26 | $28.84 | $35.48 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $29.51 / $42.66 / $100.00
| Professional | TC | $29.51 | $42.66 | $100.00 |