- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $85.11 / $131.83 / $181.97
| Professional | | $85.11 | $131.83 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $134.90 / $204.17
| Professional | 26 | $70.79 | $134.90 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $28.84 / $45.71 / $61.66
| Professional | TC | $28.84 | $45.71 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $102.33 / $223.87
| Professional | | $61.66 | $102.33 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $158.49 / $223.87
| Professional | | $109.65 | $158.49 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $104.71 / $138.04
| Professional | 26 | $83.18 | $104.71 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.70 / $64.57 / $89.13
| Professional | TC | $25.70 | $64.57 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $32.36 / $32.36 / $33.11
| Professional | | $32.36 | $32.36 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $199.53 / $309.03
| Professional | | $109.65 | $199.53 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $112.20 / $138.04
| Professional | 26 | $85.11 | $112.20 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $25.70 / $64.57 / $89.13
| Professional | TC | $25.70 | $64.57 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $85.11 / $223.87
| Professional | | $70.79 | $85.11 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $50.12 / $54.95 / $173.78
| Professional | 26 | $50.12 | $54.95 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.85 / $33.11 / $51.29
| Professional | TC | $15.85 | $33.11 | $51.29 |