- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $380.19 / $870.96
| Professional | | $208.93 | $380.19 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $125.89 / $288.40
| Professional | 26 | $56.23 | $125.89 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $190.55 / $309.03
| Professional | TC | $141.25 | $190.55 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $346.74 / $346.74
| Professional | | $95.50 | $346.74 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $112.20
| Facility | 26 | $95.50 | $95.50 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $309.03 / $524.81
| Professional | | $229.09 | $309.03 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $87.10 / $141.25
| Professional | 26 | $69.18 | $87.10 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $154.88 / $229.09 / $380.19
| Professional | TC | $154.88 | $229.09 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $380.19 / $478.63
| Professional | | $346.74 | $380.19 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $95.50 / $112.20
| Facility | 26 | $95.50 | $95.50 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $398.11 / $524.81
| Professional | | $288.40 | $398.11 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $91.20 / $134.90
| Professional | 26 | $66.07 | $91.20 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $251.19 / $316.23
| Professional | TC | $169.82 | $251.19 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $371.54 / $446.68
| Professional | | $263.03 | $371.54 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $104.71 / $123.03
| Professional | 26 | $72.44 | $104.71 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $190.55 / $269.15 / $316.23
| Professional | TC | $190.55 | $269.15 | $316.23 |