- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $109.65 / $831.76
| Professional | | $81.28 | $109.65 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $26.92 / $245.47
| Professional | 26 | $20.89 | $26.92 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $72.44 / $645.65
| Professional | TC | $52.48 | $72.44 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $48.98 / $48.98
| Professional | | $48.98 | $48.98 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $30.20 / $30.20
| Professional | 26 | $30.20 | $30.20 | $30.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $120.23 / $120.23
| Professional | | $120.23 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $87.10 / $162.18
| Professional | | $33.88 | $87.10 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.80 / $28.84 / $56.23
| Professional | 26 | $13.80 | $28.84 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $20.42 / $52.48 / $120.23
| Professional | TC | $20.42 | $52.48 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $93.33 / $758.58
| Professional | | $56.23 | $93.33 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $34.67 / $181.97
| Professional | 26 | $18.20 | $34.67 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $64.57 / $575.44
| Professional | TC | $38.02 | $64.57 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $91.20 / $131.83
| Professional | | $56.23 | $91.20 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $30.20 / $42.66
| Professional | 26 | $18.20 | $30.20 | $42.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.02 / $61.66 / $89.13
| Professional | TC | $38.02 | $61.66 | $89.13 |