- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $131.83 / $891.25
| Professional | | $83.18 | $131.83 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $38.02 / $204.17
| Professional | 26 | $25.12 | $38.02 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $93.33 / $691.83
| Professional | TC | $57.54 | $93.33 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $181.97 / $239.88
| Professional | | $104.71 | $181.97 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $52.48 / $70.79
| Professional | 26 | $23.99 | $52.48 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $128.82 / $169.82
| Professional | TC | $81.28 | $128.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $117.49 / $416.87
| Professional | | $53.70 | $117.49 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.60 / $33.88 / $123.03
| Professional | 26 | $16.60 | $33.88 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $85.11 / $316.23
| Professional | TC | $38.90 | $85.11 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $186.21 / $331.13
| Professional | | $120.23 | $186.21 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $54.95 / $97.72
| Professional | 26 | $36.31 | $54.95 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $85.11 / $131.83 / $234.42
| Professional | TC | $85.11 | $131.83 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $141.25 / $380.19
| Professional | | $107.15 | $141.25 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $31.62 / $41.69 / $109.65
| Professional | 26 | $31.62 | $41.69 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $97.72 / $269.15
| Professional | TC | $77.62 | $97.72 | $269.15 |