- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $213.80 / $416.87
| Professional | | $144.54 | $213.80 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $30.90 / $58.88
| Professional | 26 | $21.88 | $30.90 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $186.21 / $371.54
| Professional | TC | $134.90 | $186.21 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $37.15 / $37.15 / $251.19
| Professional | | $37.15 | $37.15 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $37.15 / $43.65
| Facility | 26 | $37.15 | $37.15 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $245.47 / $398.11
| Professional | | $151.36 | $245.47 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $33.11 / $54.95
| Professional | 26 | $25.12 | $33.11 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $208.93 / $346.74
| Professional | TC | $125.89 | $208.93 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $275.42 / $338.84
| Professional | | $275.42 | $275.42 | $338.84 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $37.15 / $43.65
| Facility | 26 | $37.15 | $37.15 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $281.84 / $398.11
| Professional | | $208.93 | $281.84 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $34.67 / $52.48
| Professional | 26 | $25.12 | $34.67 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $208.93 / $309.03
| Professional | TC | $141.25 | $208.93 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $275.42 / $371.54
| Professional | | $208.93 | $275.42 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $40.74 / $66.07
| Professional | 26 | $28.18 | $40.74 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $177.83 / $234.42 / $323.59
| Professional | TC | $177.83 | $234.42 | $323.59 |