- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $57.54 / $107.15 / $204.17
| Professional | | $57.54 | $107.15 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $125.89 / $257.04
| Professional | 26 | $37.15 | $125.89 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.95 / $36.31 / $66.07
| Professional | TC | $19.95 | $36.31 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $144.54
| Professional | | $93.33 | $93.33 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $144.54 / $177.83
| Professional | | $144.54 | $144.54 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $104.71
| Professional | 26 | $93.33 | $93.33 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $50.12 / $72.44
| Professional | TC | $50.12 | $50.12 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $162.18 / $218.78
| Professional | | $154.88 | $162.18 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $89.13 / $144.54 / $208.93
| Professional | | $89.13 | $144.54 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $93.33 / $138.04
| Professional | 26 | $57.54 | $93.33 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $30.90 / $50.12 / $72.44
| Professional | TC | $30.90 | $50.12 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $61.66 / $158.49
| Professional | | $54.95 | $61.66 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $39.81 / $104.71
| Professional | 26 | $38.90 | $39.81 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.85 / $21.38 / $45.71
| Professional | TC | $15.85 | $21.38 | $45.71 |