- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $125.89 / $125.89
| Professional | | $93.33 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $18.20 / $18.20 / $18.20
| Professional | 26 | $18.20 | $18.20 | $18.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $107.15 / $107.15
| Professional | TC | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $154.88 / $245.47
| Professional | | $102.33 | $154.88 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $36.31 / $36.31
| Professional | 26 | $22.91 | $36.31 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $208.93 / $208.93
| Professional | TC | $131.83 | $208.93 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $33.88 / $131.83 / $346.74
| Professional | | $33.88 | $131.83 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.31 / $18.62 / $51.29
| Professional | 26 | $6.31 | $18.62 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $27.54 / $114.82 / $295.12
| Professional | TC | $27.54 | $114.82 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $46.77 / $50.12 / $630.96
| Professional | | $46.77 | $50.12 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $6.92 / $7.59 / $95.50
| Professional | 26 | $6.92 | $7.59 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $38.90 / $42.66 / $537.03
| Professional | TC | $38.90 | $42.66 | $537.03 |