- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $169.82 / $363.08
| Professional | | $83.18 | $169.82 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $75.86 / $204.17
| Professional | 26 | $34.67 | $75.86 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $46.77 / $74.13 / $177.83
| Professional | TC | $46.77 | $74.13 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $56.23 / $134.90 / $134.90
| Professional | | $56.23 | $134.90 | $134.90 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $56.23 / $70.79
| Facility | 26 | $56.23 | $56.23 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $128.82 / $204.17
| Professional | | $97.72 | $128.82 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.02 / $56.23 / $85.11
| Professional | 26 | $38.02 | $56.23 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $58.88 / $77.62 / $112.20
| Professional | TC | $58.88 | $77.62 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $181.97
| Professional | | $147.91 | $147.91 | $181.97 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $56.23 / $70.79
| Facility | 26 | $56.23 | $56.23 | $70.79 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $151.36 / $204.17
| Professional | | $114.82 | $151.36 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $56.23 / $75.86
| Professional | 26 | $38.90 | $56.23 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $58.88 / $77.62 / $107.15
| Professional | TC | $58.88 | $77.62 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $93.33 / $158.49
| Professional | | $89.13 | $93.33 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $40.74 / $87.10
| Professional | 26 | $38.90 | $40.74 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $48.98 / $54.95 / $95.50
| Professional | TC | $48.98 | $54.95 | $95.50 |