- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $295.12
| Professional | | $295.12 | $295.12 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $35.48 / $35.48 / $35.48
| Professional | 26 | $35.48 | $35.48 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $257.04 / $257.04 / $257.04
| Professional | TC | $257.04 | $257.04 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $389.05 / $616.60
| Professional | | $257.04 | $389.05 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $46.77 / $74.13 / $74.13
| Professional | 26 | $46.77 | $74.13 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $338.84 / $537.03 / $537.03
| Professional | TC | $338.84 | $537.03 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $323.59 / $912.01
| Professional | | $61.66 | $323.59 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.18 / $36.31 / $102.33
| Professional | 26 | $13.18 | $36.31 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $48.98 / $281.84 / $812.83
| Professional | TC | $48.98 | $281.84 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $120.23 / $407.38
| Professional | | $109.65 | $120.23 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.49 / $15.49 / $52.48
| Professional | 26 | $13.49 | $15.49 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $107.15 / $363.08
| Professional | TC | $93.33 | $107.15 | $363.08 |