- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $158.49 / $275.42
| Professional | | $125.89 | $158.49 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $54.95 / $120.23
| Professional | 26 | $42.66 | $54.95 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $85.11 / $107.15 / $223.87
| Professional | TC | $85.11 | $107.15 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $64.57 / $257.04
| Professional | | $64.57 | $64.57 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $64.57 / $77.62
| Facility | 26 | $64.57 | $64.57 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $177.83 / $275.42
| Professional | | $114.82 | $177.83 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $61.66 / $109.65
| Professional | 26 | $37.15 | $61.66 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $104.71 / $204.17
| Professional | TC | $61.66 | $104.71 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $275.42 / $426.58
| Professional | | $151.36 | $275.42 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $64.57 / $77.62
| Facility | 26 | $64.57 | $64.57 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $295.12 / $407.38
| Professional | | $144.54 | $295.12 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $64.57 / $97.72
| Professional | 26 | $39.81 | $64.57 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $112.20 / $263.03
| Professional | TC | $64.57 | $112.20 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $173.78 / $218.78
| Professional | | $131.83 | $173.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $44.67 / $70.79 / $83.18
| Professional | 26 | $44.67 | $70.79 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $100.00 / $144.54
| Professional | TC | $81.28 | $100.00 | $144.54 |