- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $251.19 / $478.63
| Professional | | $165.96 | $251.19 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $93.33 / $281.84
| Professional | 26 | $60.26 | $93.33 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $128.82 / $251.19
| Professional | TC | $72.44 | $128.82 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $257.04
| Professional | | $144.54 | $144.54 | $257.04 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $177.83
| Facility | 26 | $144.54 | $144.54 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $380.19 / $467.74
| Professional | | $208.93 | $380.19 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $117.49 / $234.42
| Professional | 26 | $64.57 | $117.49 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $181.97 / $398.11
| Professional | TC | $114.82 | $181.97 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $288.40 / $426.58
| Professional | | $275.42 | $288.40 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $177.83
| Facility | 26 | $144.54 | $144.54 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $363.08 / $467.74
| Professional | | $239.88 | $363.08 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $131.83 / $208.93
| Professional | 26 | $87.10 | $131.83 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $75.86 / $138.04 / $316.23
| Professional | TC | $75.86 | $138.04 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $269.15 / $446.68
| Professional | | $177.83 | $269.15 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $97.72 / $165.96
| Professional | 26 | $64.57 | $97.72 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $125.89 / $346.74
| Professional | TC | $81.28 | $125.89 | $346.74 |