- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $134.90 / $398.11
| Professional | | $109.65 | $134.90 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $50.12 / $89.13 / $269.15
| Professional | 26 | $50.12 | $89.13 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $77.62 / $151.36
| Professional | TC | $60.26 | $77.62 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $190.55
| Professional | | $128.82 | $128.82 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $95.50
| Professional | 26 | $63.10 | $63.10 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $64.57 / $95.50
| Professional | TC | $64.57 | $64.57 | $95.50 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $89.13 / $169.82
| Facility | | $64.57 | $89.13 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $95.50 / $147.91
| Professional | | $61.66 | $95.50 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $144.54 / $245.47
| Professional | | $67.61 | $144.54 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $75.86 / $117.49
| Professional | 26 | $33.11 | $75.86 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $70.79 / $128.82
| Professional | TC | $28.84 | $70.79 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $194.98 / $269.15
| Professional | | $194.98 | $194.98 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $93.33 / $128.82
| Professional | 26 | $81.28 | $93.33 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $112.20
| Professional | TC | $112.20 | $112.20 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $125.89 / $194.98
| Professional | | $83.18 | $125.89 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $64.57 / $97.72
| Professional | 26 | $39.81 | $64.57 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $41.69 / $58.88 / $107.15
| Professional | TC | $41.69 | $58.88 | $107.15 |