- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $288.40 / $891.25
| Professional | | $199.53 | $288.40 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $117.49 / $151.36 / $501.19
| Professional | 26 | $117.49 | $151.36 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $75.86 / $91.20 / $169.82
| Professional | TC | $75.86 | $91.20 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $190.55 / $218.78
| Professional | | $181.97 | $190.55 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $158.49
| Professional | 26 | $114.82 | $114.82 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $177.83 / $316.23
| Professional | | $141.25 | $177.83 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $95.50 / $177.83
| Professional | 26 | $77.62 | $95.50 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $74.13 / $138.04
| Professional | TC | $60.26 | $74.13 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $31.62 / $147.91 / $208.93
| Facility | 26 | $31.62 | $147.91 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $281.84 / $489.78
| Professional | | $204.17 | $281.84 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $123.03 / $169.82 / $288.40
| Professional | 26 | $123.03 | $169.82 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $114.82 / $208.93
| Professional | TC | $81.28 | $114.82 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $302.00 / $588.84 / $588.84
| Facility | 26 | $302.00 | $588.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $288.40 / $1,380.38
| Professional | | $199.53 | $288.40 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $117.49 / $165.96 / $831.76
| Professional | 26 | $117.49 | $165.96 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $83.18 / $120.23 / $549.54
| Professional | TC | $83.18 | $120.23 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $251.19 / $436.52
| Professional | | $186.21 | $251.19 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $112.20 / $147.91 / $257.04
| Professional | 26 | $112.20 | $147.91 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $104.71 / $181.97
| Professional | TC | $79.43 | $104.71 | $181.97 |