- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $371.54 / $537.03
| Professional | | $213.80 | $371.54 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $85.11 / $151.36
| Professional | 26 | $56.23 | $85.11 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $151.36 / $269.15 / $398.11
| Professional | TC | $151.36 | $269.15 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $323.59
| Professional | | $93.33 | $93.33 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $114.82
| Facility | 26 | $93.33 | $93.33 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $398.11 / $616.60
| Professional | | $281.84 | $398.11 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $41.69 / $93.33 / $165.96
| Professional | 26 | $41.69 | $93.33 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $151.36 / $338.84 / $467.74
| Professional | TC | $151.36 | $338.84 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $380.19 / $588.84
| Professional | | $346.74 | $380.19 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $114.82
| Facility | 26 | $93.33 | $93.33 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $457.09 / $549.54
| Professional | | $323.59 | $457.09 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $93.33 / $134.90
| Professional | 26 | $61.66 | $93.33 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $154.88 / $275.42 / $363.08
| Professional | TC | $154.88 | $275.42 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $316.23 / $512.86
| Professional | | $199.53 | $316.23 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $56.23 / $114.82
| Professional | 26 | $52.48 | $56.23 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $245.47 / $407.38
| Professional | TC | $144.54 | $245.47 | $407.38 |