- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $89.13 / $204.17
| Professional | | $61.66 | $89.13 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.14 / $21.88 / $50.12
| Professional | 26 | $15.14 | $21.88 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $46.77 / $67.61 / $117.49
| Professional | TC | $46.77 | $67.61 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $102.33 / $123.03
| Professional | | $102.33 | $102.33 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $123.03 / $302.00
| Professional | | $104.71 | $123.03 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $24.55 / $28.84 / $61.66
| Professional | 26 | $24.55 | $28.84 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $95.50 / $245.47
| Professional | TC | $79.43 | $95.50 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $81.28 / $81.28 / $81.28
| Professional | | $81.28 | $81.28 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $20.42 / $20.42
| Professional | 26 | $20.42 | $20.42 | $20.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $60.26 / $60.26
| Professional | TC | $60.26 | $60.26 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $120.23 / $251.19
| Professional | | $95.50 | $120.23 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.42 / $28.18 / $51.29
| Professional | 26 | $20.42 | $28.18 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $91.20 / $204.17
| Professional | TC | $72.44 | $91.20 | $204.17 |