- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $165.96 / $257.04
| Professional | | $123.03 | $165.96 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $51.29 / $204.17
| Professional | 26 | $38.90 | $51.29 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $117.49 / $208.93
| Professional | TC | $79.43 | $117.49 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $29.51 / $75.86 / $131.83
| Professional | | $29.51 | $75.86 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $281.84 / $389.05
| Professional | | $107.15 | $281.84 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $32.36 / $69.18 / $95.50
| Professional | 26 | $32.36 | $69.18 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $213.80 / $295.12
| Professional | TC | $74.13 | $213.80 | $295.12 |
- 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
- $107.15 / $281.84 / $371.54
| Professional | | $107.15 | $281.84 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $69.18 / $95.50
| Professional | 26 | $33.11 | $69.18 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $213.80 / $295.12
| Professional | TC | $74.13 | $213.80 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $69.18 / $131.83 / $331.13
| Professional | | $69.18 | $131.83 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $36.31 / $89.13
| Professional | 26 | $21.38 | $36.31 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $47.86 / $97.72 / $245.47
| Professional | TC | $47.86 | $97.72 | $245.47 |