- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $263.03 / $512.86
| Professional | | $158.49 | $263.03 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $91.20 / $263.03
| Professional | 26 | $51.29 | $91.20 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $186.21 / $354.81
| Professional | TC | $107.15 | $186.21 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $338.84
| Professional | | $83.18 | $83.18 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $102.33
| Facility | 26 | $83.18 | $83.18 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $269.15 / $467.74
| Professional | | $190.55 | $269.15 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $83.18 / $147.91
| Professional | 26 | $37.15 | $83.18 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $177.83 / $302.00
| Professional | TC | $104.71 | $177.83 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $269.15 / $407.38
| Professional | | $257.04 | $269.15 | $407.38 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $83.18 / $102.33
| Facility | 26 | $83.18 | $83.18 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $338.84 / $416.87
| Professional | | $218.78 | $338.84 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $83.18 / $123.03
| Professional | 26 | $54.95 | $83.18 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $162.18 / $234.42
| Professional | TC | $104.71 | $162.18 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $218.78 / $346.74
| Professional | | $138.04 | $218.78 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $48.98 / $123.03
| Professional | 26 | $48.98 | $48.98 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $89.13 / $158.49 / $257.04
| Professional | TC | $89.13 | $158.49 | $257.04 |