- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $251.19 / $309.03
| Professional | | $208.93 | $251.19 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.90 / $42.66 / $213.80
| Professional | 26 | $30.90 | $42.66 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $213.80 / $645.65
| Professional | TC | $173.78 | $213.80 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $19.05 / $19.05
| Professional | 26 | $19.05 | $19.05 | $19.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $117.49 / $181.97
| Professional | | $91.20 | $117.49 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.62 / $18.62 / $43.65
| Professional | 26 | $18.62 | $18.62 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $83.18 / $138.04
| Professional | TC | $74.13 | $83.18 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $257.04 / $389.05
| Professional | | $91.20 | $257.04 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $38.90 / $67.61
| Professional | 26 | $20.89 | $38.90 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $70.79 / $162.18 / $371.54
| Professional | TC | $70.79 | $162.18 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $316.23 / $588.84
| Professional | | $181.97 | $316.23 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $27.54 / $45.71 / $79.43
| Professional | 26 | $27.54 | $45.71 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $263.03 / $501.19
| Professional | TC | $141.25 | $263.03 | $501.19 |