- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $263.03 / $870.96
| Professional | | $141.25 | $263.03 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $43.65 / $74.13 / $204.17
| Professional | 26 | $43.65 | $74.13 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $173.78 / $338.84
| Professional | TC | $91.20 | $173.78 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $208.93 / $208.93
| Professional | | $74.13 | $208.93 | $208.93 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $74.13 / $91.20
| Facility | 26 | $74.13 | $74.13 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $281.84 / $426.58
| Professional | | $190.55 | $281.84 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $74.13 / $131.83
| Professional | 26 | $33.88 | $74.13 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $204.17 / $295.12
| Professional | TC | $91.20 | $204.17 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $245.47 / $389.05
| Professional | | $223.87 | $245.47 | $389.05 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $74.13 / $91.20
| Facility | 26 | $74.13 | $74.13 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $302.00 / $363.08
| Professional | | $208.93 | $302.00 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $74.13 / $107.15
| Professional | 26 | $48.98 | $74.13 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $165.96 / $229.09
| Professional | TC | $91.20 | $165.96 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $218.78 / $371.54
| Professional | | $134.90 | $218.78 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $43.65 / $51.29 / $109.65
| Professional | 26 | $43.65 | $51.29 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $158.49 / $263.03
| Professional | TC | $91.20 | $158.49 | $263.03 |