- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $114.82 / $134.90
| Professional | | $91.20 | $114.82 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $14.13 / $19.95
| Professional | 26 | $12.02 | $14.13 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $100.00 / $120.23
| Professional | TC | $79.43 | $100.00 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $158.49 / $158.49
| Professional | | $120.23 | $158.49 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.30 / $13.18 / $21.38
| Professional | 26 | $12.30 | $13.18 | $21.38 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $107.15 / $141.25
| Professional | TC | $100.00 | $107.15 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $144.54 / $288.40
| Professional | | $91.20 | $144.54 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.30 / $21.88 / $30.20
| Professional | 26 | $12.30 | $21.88 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $128.82 / $208.93
| Professional | TC | $72.44 | $128.82 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $109.65 / $162.18
| Professional | | $87.10 | $109.65 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.59 / $15.49 / $21.88
| Professional | 26 | $12.59 | $15.49 | $21.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $97.72 / $141.25
| Professional | TC | $77.62 | $97.72 | $141.25 |