- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $165.96
| Professional | | $165.96 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $35.48 / $38.02 / $46.77
| Professional | 26 | $35.48 | $38.02 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $107.15
| Professional | | $87.10 | $87.10 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $23.44 / $28.84
| Professional | 26 | $23.44 | $23.44 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $79.43
| Professional | TC | $63.10 | $63.10 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $104.71
| Facility | 26 | $104.71 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $123.03 / $467.74
| Professional | | $85.11 | $123.03 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $32.36 / $125.89
| Professional | 26 | $22.91 | $32.36 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $102.33 / $338.84
| Professional | TC | $60.26 | $102.33 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $117.49 / $181.97
| Professional | | $109.65 | $117.49 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $33.88 / $51.29
| Professional | 26 | $30.20 | $33.88 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $85.11 / $131.83
| Professional | TC | $79.43 | $85.11 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $169.82 / $181.97
| Professional | | $169.82 | $169.82 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $46.77 / $46.77 / $51.29
| Professional | 26 | $46.77 | $46.77 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $131.83
| Professional | TC | $123.03 | $123.03 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $131.83 / $162.18
| Professional | | $97.72 | $131.83 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $37.15 / $46.77
| Professional | 26 | $22.91 | $37.15 | $46.77 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $70.79 / $97.72 / $114.82
| Professional | TC | $70.79 | $97.72 | $114.82 |