- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $141.25 / $398.11
| Professional | | $95.50 | $141.25 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $50.12 / $91.20
| Professional | 26 | $38.90 | $50.12 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $56.23 / $89.13 / $109.65
| Professional | TC | $56.23 | $89.13 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $169.82
| Professional | | $169.82 | $169.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $501.19 / $501.19 / $501.19
| Professional | TC | $501.19 | $501.19 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $154.88 / $346.74
| Professional | | $83.18 | $154.88 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $50.12 / $112.20
| Professional | 26 | $38.90 | $50.12 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $41.69 / $87.10 / $173.78
| Professional | TC | $41.69 | $87.10 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $154.88
| Professional | | $154.88 | $154.88 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $67.61
| Professional | 26 | $67.61 | $67.61 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Professional | TC | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $169.82 / $346.74
| Professional | | $104.71 | $169.82 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $41.69 / $57.54 / $100.00
| Professional | 26 | $41.69 | $57.54 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $114.82 / $204.17
| Professional | TC | $61.66 | $114.82 | $204.17 |