- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $154.88 / $316.23
| Professional | | $107.15 | $154.88 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $72.44 / $154.88
| Professional | 26 | $42.66 | $72.44 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $89.13 / $165.96
| Professional | TC | $52.48 | $89.13 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $338.84 / $338.84 / $338.84
| Facility | 26 | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $524.81
| Professional | | $158.49 | $158.49 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $269.15
| Professional | 26 | $81.28 | $81.28 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $77.62 / $89.13
| Professional | TC | $77.62 | $77.62 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $331.13 / $549.54
| Professional | | $177.83 | $331.13 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $81.28 / $194.98
| Professional | 26 | $74.13 | $81.28 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $75.86 / $154.88 / $416.87
| Professional | TC | $75.86 | $154.88 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $151.36
| Professional | | $151.36 | $151.36 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $54.95 / $54.95
| Professional | 26 | $54.95 | $54.95 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $97.72
| Professional | TC | $97.72 | $97.72 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $194.98 / $616.60
| Professional | | $134.90 | $194.98 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $81.28 / $162.18
| Professional | 26 | $67.61 | $81.28 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $66.07 / $93.33 / $446.68
| Professional | TC | $66.07 | $93.33 | $446.68 |