- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $177.83 / $389.05
| Professional | | $114.82 | $177.83 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $75.86 / $131.83
| Professional | 26 | $53.70 | $75.86 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $85.11 / $173.78
| Professional | TC | $52.48 | $85.11 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $186.21
| Professional | | $93.33 | $93.33 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $109.65
| Facility | 26 | $93.33 | $93.33 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $186.21 / $323.59
| Professional | | $151.36 | $186.21 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $83.18 / $138.04
| Professional | 26 | $61.66 | $83.18 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $104.71 / $165.96
| Professional | TC | $77.62 | $104.71 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $204.17 / $288.40
| Professional | | $199.53 | $204.17 | $288.40 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $109.65
| Facility | 26 | $93.33 | $93.33 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $208.93 / $309.03
| Professional | | $158.49 | $208.93 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $87.10 / $131.83
| Professional | 26 | $61.66 | $87.10 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $91.20 / $138.04
| Professional | TC | $77.62 | $91.20 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $204.17 / $302.00
| Professional | | $154.88 | $204.17 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $100.00 / $120.23
| Professional | 26 | $70.79 | $100.00 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $102.33 / $181.97
| Professional | TC | $77.62 | $102.33 | $181.97 |