- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $302.00 / $575.44
| Professional | | $199.53 | $302.00 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $45.71 / $131.83
| Professional | 26 | $33.11 | $45.71 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $263.03 / $691.83
| Professional | TC | $169.82 | $263.03 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $245.47 / $436.52
| Professional | | $120.23 | $245.47 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $34.67 / $74.13
| Professional | 26 | $20.89 | $34.67 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $208.93 / $380.19
| Professional | TC | $102.33 | $208.93 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $537.03 / $758.58
| Professional | | $263.03 | $537.03 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $79.43 / $112.20
| Professional | 26 | $38.90 | $79.43 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $457.09 / $645.65
| Professional | TC | $223.87 | $457.09 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $602.56 / $1,000.00
| Professional | | $363.08 | $602.56 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $43.65 / $70.79 / $138.04
| Professional | 26 | $43.65 | $70.79 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $288.40 / $407.38 / $851.14
| Professional | TC | $288.40 | $407.38 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $549.54 / $851.14
| Professional | | $245.47 | $549.54 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $41.69 / $117.49
| Professional | 26 | $22.91 | $41.69 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $117.49 / $245.47 / $676.08
| Professional | TC | $117.49 | $245.47 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $676.08 / $933.25
| Professional | | $457.09 | $676.08 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $89.13 / $128.82
| Professional | 26 | $60.26 | $89.13 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $398.11 / $575.44 / $794.33
| Professional | TC | $398.11 | $575.44 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $323.59 / $954.99
| Professional | | $173.78 | $323.59 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.92 / $43.65 / $131.83
| Professional | 26 | $26.92 | $43.65 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $275.42 / $812.83
| Professional | TC | $147.91 | $275.42 | $812.83 |