- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $134.90 / $478.63
| Professional | | $107.15 | $134.90 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $204.17 / $478.63
| Professional | 26 | $52.48 | $204.17 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $102.33 / $295.12
| Professional | TC | $57.54 | $102.33 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $218.78 / $218.78
| Professional | 26 | $33.11 | $218.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $63.10 / $245.47 / $323.59
| Professional | | $63.10 | $245.47 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $112.20 / $147.91
| Professional | 26 | $30.20 | $112.20 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.11 / $134.90 / $177.83
| Professional | TC | $33.11 | $134.90 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $162.18 / $467.74
| Professional | | $83.18 | $162.18 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $70.79 / $186.21
| Professional | 26 | $33.11 | $70.79 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $93.33 / $281.84
| Professional | TC | $38.90 | $93.33 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $257.04 / $524.81
| Professional | | $190.55 | $257.04 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $117.49 / $204.17
| Professional | 26 | $75.86 | $117.49 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $117.49 / $181.97 / $316.23
| Professional | TC | $117.49 | $181.97 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $223.87 / $602.56
| Professional | | $158.49 | $223.87 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $89.13 / $234.42
| Professional | 26 | $72.44 | $89.13 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $85.11 / $134.90 / $281.84
| Professional | TC | $85.11 | $134.90 | $281.84 |