- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $302.00 / $676.08
| Professional | | $165.96 | $302.00 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $100.00 / $288.40
| Professional | 26 | $52.48 | $100.00 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $199.53 / $467.74
| Professional | TC | $109.65 | $199.53 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $245.47 / $245.47
| Professional | | $83.18 | $245.47 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $102.33
| Facility | 26 | $83.18 | $83.18 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $295.12 / $478.63
| Professional | | $218.78 | $295.12 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.02 / $83.18 / $147.91
| Professional | 26 | $38.02 | $83.18 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $204.17 / $371.54
| Professional | TC | $107.15 | $204.17 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $275.42 / $501.19
| Professional | | $269.15 | $275.42 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $102.33
| Facility | 26 | $83.18 | $83.18 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $354.81 / $426.58
| Professional | | $223.87 | $354.81 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $83.18 / $125.89
| Professional | 26 | $54.95 | $83.18 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $169.82 / $245.47
| Professional | TC | $109.65 | $169.82 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $257.04 / $363.08
| Professional | | $144.54 | $257.04 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $57.54 / $123.03
| Professional | 26 | $48.98 | $57.54 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $173.78 / $288.40
| Professional | TC | $95.50 | $173.78 | $288.40 |