- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $208.93 / $389.05
| Professional | | $123.03 | $208.93 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $75.86 / $165.96
| Professional | 26 | $51.29 | $75.86 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $58.88 / $107.15 / $239.88
| Professional | TC | $58.88 | $107.15 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $199.53
| Professional | | $104.71 | $104.71 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $128.82
| Facility | 26 | $104.71 | $104.71 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $288.40 / $446.68
| Professional | | $158.49 | $288.40 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $93.33 / $158.49
| Professional | 26 | $56.23 | $93.33 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $141.25 / $389.05
| Professional | TC | $95.50 | $141.25 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $223.87 / $331.13
| Professional | | $213.80 | $223.87 | $331.13 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $128.82
| Facility | 26 | $104.71 | $104.71 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $281.84 / $371.54
| Professional | | $181.97 | $281.84 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $93.33 / $154.88
| Professional | 26 | $64.57 | $93.33 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $107.15 / $208.93
| Professional | TC | $63.10 | $107.15 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $208.93 / $389.05
| Professional | | $141.25 | $208.93 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $72.44 / $125.89
| Professional | 26 | $57.54 | $72.44 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $69.18 / $109.65 / $316.23
| Professional | TC | $69.18 | $109.65 | $316.23 |