- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $107.15 / $181.97
| Professional | | $91.20 | $107.15 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $77.62 / $107.15
| Professional | 26 | $69.18 | $77.62 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $19.05 / $28.84 / $38.02
| Professional | TC | $19.05 | $28.84 | $38.02 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $97.72
| Professional | | $91.20 | $91.20 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $89.13
| Professional | 26 | $67.61 | $67.61 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $67.61 / $104.71 / $169.82
| Professional | | $67.61 | $104.71 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $77.62 / $120.23
| Professional | 26 | $53.70 | $77.62 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $14.45 / $20.42 / $33.11
| Professional | TC | $14.45 | $20.42 | $33.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $25.70 / $77.62 / $125.89
| Professional | | $25.70 | $77.62 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $114.82 / $165.96
| Professional | | $87.10 | $114.82 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $87.10 / $114.82
| Professional | 26 | $67.61 | $87.10 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.22 / $23.99 / $40.74
| Professional | TC | $16.22 | $23.99 | $40.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $83.18 / $102.33 / $147.91
| Professional | | $83.18 | $102.33 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $79.43 / $117.49
| Professional | 26 | $64.57 | $79.43 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $16.98 / $23.99 / $37.15
| Professional | TC | $16.98 | $23.99 | $37.15 |