- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $218.78 / $870.96
| Professional | | $144.54 | $218.78 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $97.72 / $213.80 / $501.19
| Professional | 26 | $97.72 | $213.80 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.18 / $67.61 / $190.55
| Professional | TC | $28.18 | $67.61 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $223.87
| Professional | | $165.96 | $165.96 | $223.87 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $208.93
| Facility | 26 | $165.96 | $165.96 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $309.03 / $436.52
| Professional | | $117.49 | $309.03 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $138.04 / $316.23
| Professional | 26 | $89.13 | $138.04 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.92 / $97.72 / $331.13
| Professional | TC | $26.92 | $97.72 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $245.47 / $1,258.93
| Professional | | $239.88 | $245.47 | $1,258.93 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $208.93
| Facility | 26 | $165.96 | $165.96 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $223.87 / $338.84
| Professional | | $138.04 | $223.87 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $151.36 / $208.93
| Professional | 26 | $102.33 | $151.36 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $29.51 / $45.71 / $97.72
| Professional | TC | $29.51 | $45.71 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $208.93 / $371.54
| Professional | | $169.82 | $208.93 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $125.89 / $138.04 / $186.21
| Professional | 26 | $125.89 | $138.04 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $32.36 / $45.71 / $144.54
| Professional | TC | $32.36 | $45.71 | $144.54 |