- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $269.15 / $933.25
| Professional | | $162.18 | $269.15 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $107.15 / $204.17
| Professional | 26 | $58.88 | $107.15 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $177.83 / $323.59
| Professional | TC | $100.00 | $177.83 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $239.88
| Professional | | $95.50 | $95.50 | $239.88 |
- 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
- $186.21 / $281.84 / $467.74
| Professional | | $186.21 | $281.84 | $467.74 |
- 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
- $97.72 / $190.55 / $288.40
| Professional | TC | $97.72 | $190.55 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $275.42 / $398.11
| Professional | | $263.03 | $275.42 | $398.11 |
- 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 / $338.84 / $416.87
| Professional | | $223.87 | $338.84 | $416.87 |
- 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
- $100.00 / $165.96 / $223.87
| Professional | TC | $100.00 | $165.96 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $218.78 / $389.05
| Professional | | $141.25 | $218.78 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $56.23 / $141.25
| Professional | 26 | $56.23 | $56.23 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $154.88 / $263.03
| Professional | TC | $87.10 | $154.88 | $263.03 |