- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $309.03 / $741.31
| Professional | | $257.04 | $309.03 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $138.04 / $251.19 / $489.78
| Professional | 26 | $138.04 | $251.19 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $147.91 / $346.74
| Professional | TC | $123.03 | $147.91 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $457.09 / $457.09
| Professional | | $457.09 | $457.09 | $457.09 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $295.12
| Facility | 26 | $239.88 | $239.88 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $371.54 / $870.96
| Professional | | $239.88 | $371.54 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $128.82 / $194.98 / $457.09
| Professional | 26 | $128.82 | $194.98 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $194.98 / $416.87
| Professional | TC | $112.20 | $194.98 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $457.09 / $501.19 / $794.33
| Professional | | $457.09 | $501.19 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $295.12
| Facility | 26 | $239.88 | $239.88 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $446.68 / $562.34
| Professional | | $288.40 | $446.68 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $154.88 / $213.80 / $302.00
| Professional | 26 | $154.88 | $213.80 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $186.21 / $269.15
| Professional | TC | $134.90 | $186.21 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $371.54 / $501.19
| Professional | | $346.74 | $371.54 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $181.97 / $194.98 / $263.03
| Professional | 26 | $181.97 | $194.98 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $173.78 / $234.42
| Professional | TC | $162.18 | $173.78 | $234.42 |