- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $114.82 / $257.04
| Professional | | $93.33 | $114.82 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $70.79 / $151.36
| Professional | 26 | $57.54 | $70.79 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $48.98 / $85.11
| Professional | TC | $30.90 | $48.98 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $165.96
| Professional | | $93.33 | $93.33 | $165.96 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $109.65
| Facility | 26 | $93.33 | $93.33 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $147.91 / $234.42
| Professional | | $107.15 | $147.91 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $93.33 / $141.25
| Professional | 26 | $67.61 | $93.33 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $50.12 / $97.72
| Professional | TC | $30.90 | $50.12 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $177.83 / $186.21
| Professional | | $134.90 | $177.83 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $109.65
| Facility | 26 | $93.33 | $93.33 | $109.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $154.88 / $263.03
| Professional | | $107.15 | $154.88 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $87.10 / $114.82
| Professional | 26 | $60.26 | $87.10 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $60.26 / $91.20
| Professional | TC | $30.90 | $60.26 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $158.49 / $199.53
| Professional | | $120.23 | $158.49 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $104.71 / $123.03
| Professional | 26 | $77.62 | $104.71 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $41.69 / $54.95 / $69.18
| Professional | TC | $41.69 | $54.95 | $69.18 |