- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $131.83 / $181.97
| Professional | | $69.18 | $131.83 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $117.49 / $181.97
| Professional | 26 | $52.48 | $117.49 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.85 / $36.31 / $61.66
| Professional | TC | $15.85 | $36.31 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $181.97
| Professional | | $134.90 | $134.90 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $181.97 / $245.47
| Professional | | $181.97 | $181.97 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $144.54
| Professional | 26 | $134.90 | $134.90 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $46.77 / $46.77 / $102.33
| Professional | TC | $46.77 | $46.77 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $199.53 / $234.42
| Professional | | $151.36 | $199.53 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $177.83 / $269.15
| Professional | | $107.15 | $177.83 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $134.90 / $199.53
| Professional | 26 | $81.28 | $134.90 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.70 / $42.66 / $102.33
| Professional | TC | $25.70 | $42.66 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $85.11 / $194.98
| Professional | | $70.79 | $85.11 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $54.95 / $147.91
| Professional | 26 | $53.70 | $54.95 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.85 / $26.92 / $45.71
| Professional | TC | $15.85 | $26.92 | $45.71 |