- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $363.08 / $416.87
| Professional | | $204.17 | $363.08 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.02 / $47.86 / $676.08
| Professional | 26 | $38.02 | $47.86 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $165.96 / $309.03 / $354.81
| Professional | TC | $165.96 | $309.03 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $114.82 / $354.81
| Professional | | $29.51 | $114.82 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $269.15 / $398.11
| Professional | | $204.17 | $269.15 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $52.48 / $69.18
| Professional | 26 | $40.74 | $52.48 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $158.49 / $208.93 / $346.74
| Professional | TC | $158.49 | $208.93 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $302.00 / $776.25
| Professional | | $213.80 | $302.00 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $56.23 / $69.18
| Professional | 26 | $42.66 | $56.23 | $69.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $165.96 / $213.80 / $346.74
| Professional | TC | $165.96 | $213.80 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $208.93 / $562.34
| Professional | | $117.49 | $208.93 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $27.54 / $87.10
| Professional | 26 | $25.70 | $27.54 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $181.97 / $478.63
| Professional | TC | $91.20 | $181.97 | $478.63 |