- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $70.79 / $70.79 / $199.53
| Professional | | $70.79 | $70.79 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $19.05 / $52.48
| Professional | 26 | $19.05 | $19.05 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $52.48 / $147.91
| Professional | TC | $52.48 | $52.48 | $147.91 |
- 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
- $120.23 / $120.23 / $204.17
| Professional | | $120.23 | $120.23 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $40.74 / $40.74 / $51.29
| Professional | 26 | $40.74 | $40.74 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $79.43 / $151.36
| Professional | TC | $79.43 | $79.43 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $218.78 / $245.47
| Professional | | $177.83 | $218.78 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $162.18 / $302.00
| Professional | | $109.65 | $162.18 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $44.67 / $75.86
| Professional | 26 | $30.20 | $44.67 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $120.23 / $223.87
| Professional | TC | $79.43 | $120.23 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $69.18 / $199.53
| Professional | | $64.57 | $69.18 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.05 / $20.42 / $56.23
| Professional | 26 | $19.05 | $20.42 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $45.71 / $50.12 / $141.25
| Professional | TC | $45.71 | $50.12 | $141.25 |