- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $120.23 / $229.09
| Professional | | $72.44 | $120.23 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $40.74 / $218.78
| Professional | 26 | $25.12 | $40.74 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $45.71 / $85.11 / $162.18
| Professional | TC | $45.71 | $85.11 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $177.83 / $208.93
| Professional | | $177.83 | $177.83 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $77.62 / $91.20
| Professional | 26 | $72.44 | $77.62 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $120.23
| Professional | TC | $100.00 | $100.00 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $50.12 / $74.13 / $338.84
| Professional | | $50.12 | $74.13 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $30.90 / $114.82
| Professional | 26 | $19.50 | $30.90 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.20 / $47.86 / $229.09
| Professional | TC | $30.20 | $47.86 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $120.23 / $199.53
| Professional | | $74.13 | $120.23 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $43.65 / $64.57
| Professional | 26 | $25.12 | $43.65 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $47.86 / $72.44 / $128.82
| Professional | TC | $47.86 | $72.44 | $128.82 |