- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $79.43 / $109.65 / $371.54
| Professional | | $79.43 | $109.65 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $35.48 / $45.71 / $204.17
| Professional | 26 | $35.48 | $45.71 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $39.81 / $56.23 / $218.78
| Professional | TC | $39.81 | $56.23 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $123.03
| Professional | | $58.88 | $58.88 | $123.03 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $72.44
| Facility | 26 | $58.88 | $58.88 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $72.44 / $138.04 / $186.21
| Professional | | $72.44 | $138.04 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $31.62 / $58.88 / $97.72
| Professional | 26 | $31.62 | $58.88 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $39.81 / $70.79 / $112.20
| Professional | TC | $39.81 | $70.79 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $134.90 / $147.91
| Professional | | $109.65 | $134.90 | $147.91 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $72.44
| Facility | 26 | $58.88 | $58.88 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $169.82 / $204.17
| Professional | | $97.72 | $169.82 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $58.88 / $85.11
| Professional | 26 | $38.90 | $58.88 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.11 / $54.95 / $95.50
| Professional | TC | $33.11 | $54.95 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $83.18 / $162.18
| Professional | | $61.66 | $83.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $34.67 / $87.10
| Professional | 26 | $34.67 | $34.67 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.92 / $46.77 / $93.33
| Professional | TC | $26.92 | $46.77 | $93.33 |