- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $151.36 / $338.84
| Professional | | $112.20 | $151.36 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $44.67 / $51.29 / $112.20
| Professional | 26 | $44.67 | $51.29 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $97.72 / $162.18
| Professional | TC | $63.10 | $97.72 | $162.18 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $288.40 / $288.40 / $288.40
| Facility | 26 | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $199.53 / $575.44
| Professional | | $199.53 | $199.53 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $61.66 / $190.55
| Professional | 26 | $61.66 | $61.66 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $131.83 / $131.83
| Professional | TC | $131.83 | $131.83 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $257.04 / $524.81
| Professional | | $177.83 | $257.04 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $66.07 / $144.54
| Professional | 26 | $58.88 | $66.07 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $173.78 / $371.54
| Professional | TC | $81.28 | $173.78 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $48.98 / $48.98
| Professional | 26 | $48.98 | $48.98 | $48.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $104.71
| Professional | TC | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $190.55 / $380.19
| Professional | | $138.04 | $190.55 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $46.77 / $60.26 / $117.49
| Professional | 26 | $46.77 | $60.26 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $131.83 / $263.03
| Professional | TC | $93.33 | $131.83 | $263.03 |