- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $371.54 / $630.96
| Professional | | $208.93 | $371.54 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $85.11 / $162.18
| Professional | 26 | $54.95 | $85.11 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $151.36 / $269.15 / $467.74
| Professional | TC | $151.36 | $269.15 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $316.23 / $316.23
| Professional | | $89.13 | $316.23 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $109.65
| Facility | 26 | $89.13 | $89.13 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $389.05 / $630.96
| Professional | | $281.84 | $389.05 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $89.13 / $158.49
| Professional | 26 | $39.81 | $89.13 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $151.36 / $302.00 / $489.78
| Professional | TC | $151.36 | $302.00 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $371.54 / $602.56
| Professional | | $338.84 | $371.54 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $109.65
| Facility | 26 | $89.13 | $89.13 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $457.09 / $549.54
| Professional | | $316.23 | $457.09 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $89.13 / $128.82
| Professional | 26 | $58.88 | $89.13 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $151.36 / $275.42 / $371.54
| Professional | TC | $151.36 | $275.42 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $323.59 / $457.09
| Professional | | $199.53 | $323.59 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $53.70 / $131.83
| Professional | 26 | $52.48 | $53.70 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $257.04 / $407.38
| Professional | TC | $147.91 | $257.04 | $407.38 |