- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $281.84 / $691.83
| Professional | | $173.78 | $281.84 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $107.15 / $190.55
| Professional | 26 | $58.88 | $107.15 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $199.53 / $380.19
| Professional | TC | $109.65 | $199.53 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $257.04 / $257.04
| Professional | | $95.50 | $257.04 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $117.49
| Facility | 26 | $95.50 | $95.50 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $302.00 / $537.03
| Professional | | $223.87 | $302.00 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $95.50 / $169.82
| Professional | 26 | $42.66 | $95.50 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $213.80 / $380.19
| Professional | TC | $107.15 | $213.80 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $288.40 / $501.19
| Professional | | $275.42 | $288.40 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $117.49
| Facility | 26 | $95.50 | $95.50 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $389.05 / $446.68
| Professional | | $257.04 | $389.05 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $95.50 / $138.04
| Professional | 26 | $61.66 | $95.50 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $204.17 / $295.12
| Professional | TC | $109.65 | $204.17 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $257.04 / $389.05
| Professional | | $173.78 | $257.04 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $56.23 / $141.25
| Professional | 26 | $54.95 | $56.23 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $117.49 / $204.17 / $288.40
| Professional | TC | $117.49 | $204.17 | $288.40 |