- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $154.88 / $223.87
| Professional | | $123.03 | $154.88 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $36.31 / $75.86
| Professional | 26 | $28.18 | $36.31 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $117.49 / $165.96
| Professional | TC | $93.33 | $117.49 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $223.87
| Facility | 26 | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $630.96
| Professional | | $165.96 | $165.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $47.86 / $47.86 / $151.36
| Professional | 26 | $47.86 | $47.86 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $147.91
| Professional | TC | $125.89 | $125.89 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $218.78 / $630.96
| Professional | | $158.49 | $218.78 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $51.29 / $151.36
| Professional | 26 | $28.18 | $51.29 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $162.18 / $346.74
| Professional | TC | $112.20 | $162.18 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $158.49 / $630.96
| Professional | | $151.36 | $158.49 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $39.81 / $151.36
| Professional | 26 | $36.31 | $39.81 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $117.49 / $120.23 / $134.90
| Professional | TC | $117.49 | $120.23 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $181.97 / $380.19
| Professional | | $144.54 | $181.97 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.02 / $47.86 / $93.33
| Professional | 26 | $38.02 | $47.86 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $138.04 / $288.40
| Professional | TC | $107.15 | $138.04 | $288.40 |