- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $245.47 / $478.63
| Professional | | $147.91 | $245.47 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.90 / $43.65 / $213.80
| Professional | 26 | $30.90 | $43.65 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $213.80 / $645.65
| Professional | TC | $144.54 | $213.80 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $223.87 / $489.78
| Professional | | $117.49 | $223.87 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $44.67 / $83.18
| Professional | 26 | $23.99 | $44.67 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $186.21 / $416.87
| Professional | TC | $95.50 | $186.21 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $275.42 / $416.87
| Professional | | $204.17 | $275.42 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $29.51 / $38.02 / $57.54
| Professional | 26 | $29.51 | $38.02 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $234.42 / $354.81
| Professional | TC | $173.78 | $234.42 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $331.13 / $588.84
| Professional | | $245.47 | $331.13 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $29.51 / $46.77 / $83.18
| Professional | 26 | $29.51 | $46.77 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $213.80 / $263.03 / $501.19
| Professional | TC | $213.80 | $263.03 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $245.47 / $407.38
| Professional | | $120.23 | $245.47 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $34.67 / $58.88
| Professional | 26 | $19.50 | $34.67 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $208.93 / $363.08
| Professional | TC | $102.33 | $208.93 | $363.08 |