- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $302.00 / $851.14
| Professional | | $131.83 | $302.00 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $147.91 / $616.60
| Professional | 26 | $58.88 | $147.91 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $67.61 / $95.50 / $389.05
| Professional | TC | $67.61 | $95.50 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $199.53
| Professional | | $95.50 | $95.50 | $199.53 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $117.49
| Facility | 26 | $95.50 | $95.50 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $199.53 / $380.19
| Professional | | $104.71 | $199.53 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $77.62 / $181.97
| Professional | 26 | $51.29 | $77.62 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $53.70 / $114.82 / $204.17
| Professional | TC | $53.70 | $114.82 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $218.78 / $794.33
| Professional | | $213.80 | $218.78 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $117.49
| Facility | 26 | $95.50 | $95.50 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $194.98 / $288.40
| Professional | | $128.82 | $194.98 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $85.11 / $123.03
| Professional | 26 | $61.66 | $85.11 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $66.07 / $102.33 / $151.36
| Professional | TC | $66.07 | $102.33 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $190.55 / $234.42
| Professional | | $162.18 | $190.55 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $81.28 / $107.15
| Professional | 26 | $72.44 | $81.28 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $85.11 / $112.20 / $138.04
| Professional | TC | $85.11 | $112.20 | $138.04 |