- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $147.91 / $309.03
| Professional | | $95.50 | $147.91 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $52.48 / $199.53
| Professional | 26 | $18.20 | $52.48 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $48.98 / $91.20 / $213.80
| Professional | TC | $48.98 | $91.20 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $151.36
| Professional | | $70.79 | $70.79 | $151.36 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $89.13
| Facility | 26 | $70.79 | $70.79 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $181.97 / $295.12
| Professional | | $112.20 | $181.97 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $35.48 / $107.15
| Professional | 26 | $17.78 | $35.48 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $120.23 / $263.03
| Professional | TC | $81.28 | $120.23 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $165.96 / $223.87
| Professional | | $141.25 | $165.96 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $89.13
| Facility | 26 | $70.79 | $70.79 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $213.80 / $281.84
| Professional | | $134.90 | $213.80 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $47.86 / $104.71
| Professional | 26 | $23.44 | $47.86 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $53.70 / $91.20 / $173.78
| Professional | TC | $53.70 | $91.20 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $141.25 / $323.59
| Professional | | $89.13 | $141.25 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $50.12 / $87.10
| Professional | 26 | $17.78 | $50.12 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $95.50 / $309.03
| Professional | TC | $60.26 | $95.50 | $309.03 |