- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $173.78 / $323.59
| Professional | | $128.82 | $173.78 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $85.11 / $144.54
| Professional | 26 | $67.61 | $85.11 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $54.95 / $83.18 / $144.54
| Professional | TC | $54.95 | $83.18 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $251.19 / $251.19
| Professional | | $125.89 | $251.19 | $251.19 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $147.91
| Facility | 26 | $125.89 | $125.89 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $213.80 / $676.08
| Professional | | $112.20 | $213.80 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $109.65 / $338.84
| Professional | 26 | $81.28 | $109.65 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $32.36 / $107.15 / $331.13
| Professional | TC | $32.36 | $107.15 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $275.42 / $316.23
| Professional | | $229.09 | $275.42 | $316.23 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $125.89 / $125.89 / $147.91
| Facility | 26 | $125.89 | $125.89 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $331.13 / $436.52
| Professional | | $162.18 | $331.13 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $112.20 / $173.78
| Professional | 26 | $81.28 | $112.20 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $120.23 / $173.78
| Professional | TC | $81.28 | $120.23 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $269.15 / $323.59
| Professional | | $128.82 | $269.15 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $134.90 / $169.82
| Professional | 26 | $85.11 | $134.90 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $42.66 / $138.04 / $165.96
| Professional | TC | $42.66 | $138.04 | $165.96 |