- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $186.21 / $549.54
| Professional | | $109.65 | $186.21 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $51.29 / $123.03
| Professional | 26 | $32.36 | $51.29 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $51.29 / $102.33 / $257.04
| Professional | 52 | $51.29 | $102.33 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $102.33 / $229.09
| Professional | TC | $79.43 | $102.33 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $181.97 / $288.40
| Professional | | $131.83 | $181.97 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $44.67 / $77.62
| Professional | 26 | $36.31 | $44.67 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $117.49 / $213.80
| Professional | TC | $95.50 | $117.49 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $194.98 / $302.00
| Professional | | $117.49 | $194.98 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $53.70 / $79.43
| Professional | 26 | $32.36 | $53.70 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $144.54 / $218.78
| Professional | TC | $93.33 | $144.54 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $154.88 / $223.87
| Professional | | $134.90 | $154.88 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.02 / $43.65 / $56.23
| Professional | 26 | $38.02 | $43.65 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $114.82 / $151.36
| Professional | TC | $100.00 | $114.82 | $151.36 |