- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $309.03 / $891.25
| Professional | | $61.66 | $309.03 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $31.62 / $72.44 / $213.80
| Professional | 26 | $31.62 | $72.44 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $40.74 / $70.79 / $138.04
| Professional | TC | $40.74 | $70.79 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $53.70 / $165.96 / $165.96
| Professional | | $53.70 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $147.91 / $147.91 / $165.96
| Professional | | $147.91 | $147.91 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $53.70 / $58.88
| Professional | 26 | $53.70 | $53.70 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $114.82
| Professional | TC | $87.10 | $87.10 | $114.82 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $181.97 / $251.19
| Facility | | $173.78 | $181.97 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $181.97 / $251.19
| Professional | | $173.78 | $181.97 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $251.19
| Facility | | $165.96 | $165.96 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $147.91 / $257.04
| Professional | | $95.50 | $147.91 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $53.70 / $77.62
| Professional | 26 | $32.36 | $53.70 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $95.50 / $181.97
| Professional | TC | $63.10 | $95.50 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $64.57 / $173.78
| Professional | | $64.57 | $64.57 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $22.39 / $63.10
| Professional | 26 | $21.88 | $22.39 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $41.69 / $42.66 / $114.82
| Professional | TC | $41.69 | $42.66 | $114.82 |