- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $194.98 / $363.08
| Professional | | $128.82 | $194.98 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $100.00 / $501.19
| Professional | 26 | $75.86 | $100.00 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $91.20 / $177.83
| Professional | TC | $52.48 | $91.20 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $208.93 / $234.42
| Professional | | $123.03 | $208.93 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $100.00 / $112.20 / $112.20
| Professional | 26 | $100.00 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $147.91
| Professional | TC | $109.65 | $109.65 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $158.49 / $933.25
| Professional | | $107.15 | $158.49 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $72.44 / $457.09
| Professional | 26 | $52.48 | $72.44 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $89.13 / $478.63
| Professional | TC | $50.12 | $89.13 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $549.54 / $549.54
| Professional | | $288.40 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $138.04 / $263.03 / $263.03
| Professional | 26 | $138.04 | $263.03 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $151.36 / $281.84 / $281.84
| Professional | TC | $151.36 | $281.84 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $190.55 / $588.84
| Professional | | $144.54 | $190.55 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $95.50 / $269.15
| Professional | 26 | $79.43 | $95.50 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $85.11 / $309.03
| Professional | TC | $64.57 | $85.11 | $309.03 |