- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $181.97 / $478.63
| Professional | | $147.91 | $181.97 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $28.18 / $64.57
| Professional | 26 | $21.88 | $28.18 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $151.36 / $389.05
| Professional | TC | $123.03 | $151.36 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $23.44 / $169.82 / $208.93
| Professional | | $23.44 | $169.82 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $26.30 / $28.84
| Professional | 26 | $23.44 | $26.30 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $186.21
| Professional | TC | $147.91 | $147.91 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.02 / $38.02 / $38.02
| Facility | 26 | $38.02 | $38.02 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $218.78 / $363.08
| Professional | | $144.54 | $218.78 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $29.51 / $52.48
| Professional | 26 | $21.38 | $29.51 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $194.98 / $309.03
| Professional | TC | $131.83 | $194.98 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $204.17 / $288.40
| Professional | | $177.83 | $204.17 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $28.18 / $38.90
| Professional | 26 | $23.99 | $28.18 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $151.36 / $181.97 / $251.19
| Professional | TC | $151.36 | $181.97 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $213.80 / $371.54
| Professional | | $144.54 | $213.80 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $28.18 / $56.23
| Professional | 26 | $20.89 | $28.18 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $186.21 / $323.59
| Professional | TC | $123.03 | $186.21 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $223.87 / $257.04
| Professional | | $165.96 | $223.87 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.99 / $29.51 / $35.48
| Professional | 26 | $23.99 | $29.51 | $35.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $190.55 / $223.87
| Professional | TC | $144.54 | $190.55 | $223.87 |