- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $144.54 / $288.40
| Professional | | $107.15 | $144.54 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $32.36 / $56.23
| Professional | 26 | $20.89 | $32.36 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $120.23 / $229.09
| Professional | TC | $87.10 | $120.23 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $288.40 / $288.40
| Professional | | $234.42 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $43.65 / $43.65
| Professional | 26 | $34.67 | $43.65 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $194.98 / $245.47 / $245.47
| Professional | TC | $194.98 | $245.47 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $251.19 / $338.84
| Professional | | $169.82 | $251.19 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $41.69 / $72.44
| Professional | 26 | $30.20 | $41.69 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $208.93 / $281.84
| Professional | TC | $141.25 | $208.93 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $316.23 / $676.08
| Professional | | $165.96 | $316.23 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $29.51 / $52.48 / $102.33
| Professional | 26 | $29.51 | $52.48 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $269.15 / $575.44
| Professional | TC | $138.04 | $269.15 | $575.44 |