- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $120.23 / $165.96
| Professional | | $93.33 | $120.23 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.02 / $15.14 / $26.92
| Professional | 26 | $12.02 | $15.14 | $26.92 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $104.71 / $147.91
| Professional | TC | $79.43 | $104.71 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $134.90
| Professional | | $134.90 | $134.90 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $123.03 / $123.03
| Professional | | $123.03 | $123.03 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $123.03 / $177.83
| Professional | | $93.33 | $123.03 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $13.18 / $18.62 / $28.84
| Professional | 26 | $13.18 | $18.62 | $28.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $75.86 / $107.15 / $147.91
| Professional | TC | $75.86 | $107.15 | $147.91 |
- 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
- $79.43 / $102.33 / $123.03
| Professional | | $79.43 | $102.33 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $12.30 / $14.79 / $19.95
| Professional | 26 | $12.30 | $14.79 | $19.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $89.13 / $104.71
| Professional | TC | $64.57 | $89.13 | $104.71 |