- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $186.21 / $616.60
| Professional | | $109.65 | $186.21 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $67.61 / $181.97
| Professional | 26 | $36.31 | $67.61 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $107.15 / $208.93
| Professional | TC | $72.44 | $107.15 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $194.98
| Professional | | $58.88 | $58.88 | $194.98 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $74.13
| Facility | 26 | $58.88 | $58.88 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $186.21 / $288.40
| Professional | | $95.50 | $186.21 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $57.54 / $89.13
| Professional | 26 | $32.36 | $57.54 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $128.82 / $199.53
| Professional | TC | $60.26 | $128.82 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $213.80 / $323.59
| Professional | | $186.21 | $213.80 | $323.59 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $74.13
| Facility | 26 | $58.88 | $58.88 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $275.42 / $338.84
| Professional | | $162.18 | $275.42 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $57.54 / $87.10
| Professional | 26 | $36.31 | $57.54 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $85.11 / $128.82 / $190.55
| Professional | TC | $85.11 | $128.82 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $123.03 / $234.42
| Professional | | $107.15 | $123.03 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $41.69 / $87.10
| Professional | 26 | $34.67 | $41.69 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $70.79 / $81.28 / $144.54
| Professional | TC | $70.79 | $81.28 | $144.54 |