- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $263.03 / $588.84
| Professional | | $131.83 | $263.03 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $43.65 / $97.72 / $208.93
| Professional | 26 | $43.65 | $97.72 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $114.82 / $316.23
| Professional | TC | $77.62 | $114.82 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $213.80 / $213.80
| Professional | | $74.13 | $213.80 | $213.80 |
- 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
- $131.83 / $213.80 / $323.59
| Professional | | $131.83 | $213.80 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $72.44 / $109.65
| Professional | 26 | $48.98 | $72.44 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $85.11 / $141.25 / $204.17
| Professional | TC | $85.11 | $141.25 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $239.88 / $316.23
| Professional | | $234.42 | $239.88 | $316.23 |
- 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
- $169.82 / $239.88 / $323.59
| Professional | | $169.82 | $239.88 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $74.13 / $97.72
| Professional | 26 | $48.98 | $74.13 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $141.25 / $199.53
| Professional | TC | $93.33 | $141.25 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $151.36 / $323.59
| Professional | | $141.25 | $151.36 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $50.12 / $51.29 / $102.33
| Professional | 26 | $50.12 | $51.29 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $100.00 / $199.53
| Professional | TC | $91.20 | $100.00 | $199.53 |