- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $158.49 / $478.63
| Professional | | $81.28 | $158.49 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $53.70 / $144.54
| Professional | 26 | $28.18 | $53.70 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $58.88 / $100.00 / $199.53
| Professional | TC | $58.88 | $100.00 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $158.49 / $158.49
| Professional | | $46.77 | $158.49 | $158.49 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $46.77 / $46.77 / $57.54
| Facility | 26 | $46.77 | $46.77 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $151.36 / $245.47
| Professional | | $81.28 | $151.36 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $31.62 / $46.77 / $70.79
| Professional | 26 | $31.62 | $46.77 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $45.71 / $107.15 / $165.96
| Professional | TC | $45.71 | $107.15 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $173.78 / $257.04
| Professional | | $169.82 | $173.78 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $46.77 / $46.77 / $57.54
| Facility | 26 | $46.77 | $46.77 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $162.18 / $257.04
| Professional | | $97.72 | $162.18 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $31.62 / $46.77 / $63.10
| Professional | 26 | $31.62 | $46.77 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $51.29 / $102.33 / $158.49
| Professional | TC | $51.29 | $102.33 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $117.49 / $194.98
| Professional | | $74.13 | $117.49 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $33.11 / $87.10
| Professional | 26 | $32.36 | $33.11 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $42.66 / $85.11 / $141.25
| Professional | TC | $42.66 | $85.11 | $141.25 |