- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $194.98 / $676.08
| Professional | | $141.25 | $194.98 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $102.33 / $295.12
| Professional | 26 | $58.88 | $102.33 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $66.07 / $114.82 / $275.42
| Professional | TC | $66.07 | $114.82 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $218.78
| Professional | | $107.15 | $107.15 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $131.83
| Facility | 26 | $107.15 | $107.15 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $239.88 / $354.81
| Professional | | $123.03 | $239.88 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $95.50 / $181.97
| Professional | 26 | $56.23 | $95.50 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $147.91 / $245.47
| Professional | TC | $77.62 | $147.91 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $245.47 / $269.15
| Professional | | $208.93 | $245.47 | $269.15 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $131.83
| Facility | 26 | $107.15 | $107.15 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $309.03 / $380.19
| Professional | | $204.17 | $309.03 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $100.00 / $154.88
| Professional | 26 | $67.61 | $100.00 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $75.86 / $112.20 / $162.18
| Professional | TC | $75.86 | $112.20 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $147.91 / $295.12
| Professional | | $107.15 | $147.91 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $47.86 / $64.57 / $134.90
| Professional | 26 | $47.86 | $64.57 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $85.11 / $190.55
| Professional | TC | $60.26 | $85.11 | $190.55 |