- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $123.03 / $245.47
| Professional | | $93.33 | $123.03 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $70.79 / $158.49
| Professional | 26 | $53.70 | $70.79 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $39.81 / $46.77 / $89.13
| Professional | TC | $39.81 | $46.77 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $173.78 / $173.78
| Professional | | $141.25 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $97.72 / $97.72
| Professional | 26 | $79.43 | $97.72 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $77.62 / $77.62
| Professional | TC | $61.66 | $77.62 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $123.03 / $204.17
| Professional | | $91.20 | $123.03 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $81.28 / $117.49
| Professional | 26 | $64.57 | $81.28 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.30 / $36.31 / $75.86
| Professional | TC | $26.30 | $36.31 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $144.54 / $263.03
| Professional | | $109.65 | $144.54 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $97.72 / $190.55
| Professional | 26 | $75.86 | $97.72 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $36.31 / $51.29 / $89.13
| Professional | TC | $36.31 | $51.29 | $89.13 |