- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $323.59 / $630.96
| Professional | | $229.09 | $323.59 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $102.33 / $213.80
| Professional | 26 | $81.28 | $102.33 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $218.78 / $416.87
| Professional | TC | $147.91 | $218.78 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $288.40 / $489.78
| Professional | | $218.78 | $288.40 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $97.72 / $162.18
| Professional | 26 | $69.18 | $97.72 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $173.78 / $288.40
| Professional | TC | $134.90 | $173.78 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $426.58 / $870.96
| Professional | | $269.15 | $426.58 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $144.54 / $218.78
| Professional | 26 | $104.71 | $144.54 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $281.84 / $676.08
| Professional | TC | $169.82 | $281.84 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $316.23 / $524.81
| Professional | | $190.55 | $316.23 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $131.83 / $190.55
| Professional | 26 | $102.33 | $131.83 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $213.80 / $316.23
| Professional | TC | $79.43 | $213.80 | $316.23 |