- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $95.50 / $812.83
| Professional | | $75.86 | $95.50 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $28.18 / $218.78
| Professional | 26 | $21.88 | $28.18 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $53.70 / $67.61 / $602.56
| Professional | TC | $53.70 | $67.61 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $204.17 / $204.17
| Professional | | $204.17 | $204.17 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $48.98 / $114.82 / $380.19
| Professional | | $48.98 | $114.82 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.38 / $33.11 / $114.82
| Professional | 26 | $17.38 | $33.11 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.11 / $83.18 / $263.03
| Professional | TC | $33.11 | $83.18 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $204.17 / $1,202.26
| Professional | | $69.18 | $204.17 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $60.26 / $363.08
| Professional | 26 | $21.38 | $60.26 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $47.86 / $131.83 / $912.01
| Professional | TC | $47.86 | $131.83 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $125.89 / $229.09
| Professional | | $69.18 | $125.89 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $38.90 / $61.66
| Professional | 26 | $21.38 | $38.90 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $47.86 / $87.10 / $165.96
| Professional | TC | $47.86 | $87.10 | $165.96 |