- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $173.78 / $288.40
| Professional | | $104.71 | $173.78 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $33.88 / $72.44
| Professional | 26 | $22.91 | $33.88 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $120.23 / $204.17
| Professional | TC | $72.44 | $120.23 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $38.02 / $38.02 / $251.19
| Professional | | $38.02 | $38.02 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.02 / $38.02 / $45.71
| Facility | 26 | $38.02 | $38.02 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $245.47 / $426.58
| Professional | | $134.90 | $245.47 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.90 / $38.02 / $64.57
| Professional | 26 | $30.90 | $38.02 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $204.17 / $354.81
| Professional | TC | $104.71 | $204.17 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $275.42 / $363.08
| Professional | | $263.03 | $275.42 | $363.08 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.02 / $38.02 / $45.71
| Facility | 26 | $38.02 | $38.02 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $275.42 / $436.52
| Professional | | $190.55 | $275.42 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.90 / $38.02 / $67.61
| Professional | 26 | $30.90 | $38.02 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $199.53 / $288.40
| Professional | TC | $144.54 | $199.53 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $269.15 / $346.74
| Professional | | $208.93 | $269.15 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $43.65 / $53.70
| Professional | 26 | $33.11 | $43.65 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $177.83 / $223.87 / $295.12
| Professional | TC | $177.83 | $223.87 | $295.12 |