- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $316.23 / $794.33
| Professional | | $169.82 | $316.23 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $67.61 / $158.49
| Professional | 26 | $32.36 | $67.61 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $158.49 / $251.19 / $645.65
| Professional | TC | $158.49 | $251.19 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $426.58 / $426.58
| Professional | | $58.88 | $426.58 | $426.58 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $72.44
| Facility | 26 | $58.88 | $58.88 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $363.08 / $831.76
| Professional | | $173.78 | $363.08 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $31.62 / $47.86 / $112.20
| Professional | 26 | $31.62 | $47.86 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $295.12 / $707.95
| Professional | TC | $138.04 | $295.12 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $467.74 / $562.34
| Professional | | $316.23 | $467.74 | $562.34 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $72.44
| Facility | 26 | $58.88 | $58.88 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $389.05 / $524.81
| Professional | | $257.04 | $389.05 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $53.70 / $72.44
| Professional | 26 | $36.31 | $53.70 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $323.59 / $446.68
| Professional | TC | $223.87 | $323.59 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $354.81 / $478.63
| Professional | | $229.09 | $354.81 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $44.67 / $47.86 / $64.57
| Professional | 26 | $44.67 | $47.86 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $181.97 / $309.03 / $416.87
| Professional | TC | $181.97 | $309.03 | $416.87 |