- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $239.88 / $562.34
| Professional | | $70.79 | $239.88 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $58.88 / $162.18
| Professional | 26 | $25.12 | $58.88 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $53.70 / $125.89 / $177.83
| Professional | TC | $53.70 | $125.89 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $40.74 / $40.74 / $177.83
| Professional | | $40.74 | $40.74 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $177.83
| Professional | | $158.49 | $158.49 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $40.74 / $45.71
| Professional | 26 | $40.74 | $40.74 | $45.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $112.20 / $138.04
| Professional | TC | $112.20 | $112.20 | $138.04 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $194.98 / $218.78
| Facility | | $151.36 | $194.98 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $194.98 / $218.78
| Professional | | $151.36 | $194.98 | $218.78 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $158.49 / $158.49 / $251.19
| Facility | | $158.49 | $158.49 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $162.18 / $257.04
| Professional | | $107.15 | $162.18 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $24.55 / $40.74 / $58.88
| Professional | 26 | $24.55 | $40.74 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $83.18 / $123.03 / $199.53
| Professional | TC | $83.18 | $123.03 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $58.88 / $64.57 / $186.21
| Professional | | $58.88 | $64.57 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $16.60 / $16.98 / $47.86
| Professional | 26 | $16.60 | $16.98 | $47.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $42.66 / $47.86 / $138.04
| Professional | TC | $42.66 | $47.86 | $138.04 |