- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $141.25 / $234.42
| Professional | | $87.10 | $141.25 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $20.89 / $38.90
| Professional | 26 | $18.20 | $20.89 | $38.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $69.18 / $120.23 / $190.55
| Professional | TC | $69.18 | $120.23 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $436.52 / $436.52
| Professional | | $281.84 | $436.52 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $47.86 / $74.13 / $74.13
| Professional | 26 | $47.86 | $74.13 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $234.42 / $363.08 / $363.08
| Professional | TC | $234.42 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $177.83 / $257.04
| Professional | | $87.10 | $177.83 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $20.89 / $36.31 / $57.54
| Professional | 26 | $20.89 | $36.31 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $138.04 / $199.53
| Professional | TC | $61.66 | $138.04 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $173.78 / $251.19
| Professional | | $77.62 | $173.78 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $33.11 / $58.88
| Professional | 26 | $19.05 | $33.11 | $58.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $141.25 / $194.98
| Professional | TC | $57.54 | $141.25 | $194.98 |