- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $302.00
| Professional | | $87.10 | $87.10 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $25.70 / $87.10
| Professional | 26 | $25.70 | $25.70 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $61.66 / $213.80
| Professional | TC | $61.66 | $61.66 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $19.50 / $19.50
| Professional | 26 | $19.50 | $19.50 | $19.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $223.87 / $223.87
| Professional | | $151.36 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $43.65 / $64.57 / $64.57
| Professional | 26 | $43.65 | $64.57 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $158.49 / $162.18
| Professional | TC | $107.15 | $158.49 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $263.03 / $331.13
| Professional | | $165.96 | $263.03 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $77.62 / $95.50
| Professional | 26 | $58.88 | $77.62 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $190.55 / $239.88
| Professional | TC | $107.15 | $190.55 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $190.55 / $1,071.52
| Professional | | $123.03 | $190.55 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $61.66 / $389.05
| Professional | 26 | $39.81 | $61.66 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $117.49 / $794.33
| Professional | TC | $81.28 | $117.49 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $263.03 / $363.08
| Professional | | $218.78 | $263.03 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $77.62 / $104.71
| Professional | 26 | $70.79 | $77.62 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $190.55 / $257.04
| Professional | TC | $141.25 | $190.55 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $331.13 / $363.08
| Professional | | $302.00 | $331.13 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $95.50 / $104.71
| Professional | 26 | $91.20 | $95.50 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $213.80 / $239.88 / $257.04
| Professional | TC | $213.80 | $239.88 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $131.83 / $398.11
| Professional | | $117.49 | $131.83 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.02 / $42.66 / $141.25
| Professional | 26 | $38.02 | $42.66 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $93.33 / $263.03
| Professional | TC | $77.62 | $93.33 | $263.03 |