- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $74.13 / $158.49 / $177.83
| Professional | | $74.13 | $158.49 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $60.26 / $112.20
| Professional | 26 | $25.70 | $60.26 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $47.86 / $74.13 / $112.20
| Professional | TC | $47.86 | $74.13 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $66.07 / $66.07 / $186.21
| Professional | | $66.07 | $66.07 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $186.21 / $275.42
| Professional | | $186.21 | $186.21 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $66.07 / $97.72
| Professional | 26 | $66.07 | $66.07 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $177.83
| Professional | TC | $123.03 | $123.03 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $208.93 / $363.08
| Professional | | $204.17 | $208.93 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $186.21 / $275.42
| Professional | | $114.82 | $186.21 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $66.07 / $97.72
| Professional | 26 | $40.74 | $66.07 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $123.03 / $177.83
| Professional | TC | $74.13 | $123.03 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $77.62 / $89.13 / $204.17
| Professional | | $77.62 | $89.13 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $36.31 / $74.13
| Professional | 26 | $28.18 | $36.31 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $50.12 / $53.70 / $131.83
| Professional | TC | $50.12 | $53.70 | $131.83 |