- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $125.89 / $208.93
| Professional | | $91.20 | $125.89 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $15.85 / $33.11 / $54.95
| Professional | 26 | $15.85 | $33.11 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $109.65 / $173.78
| Professional | TC | $91.20 | $109.65 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $186.21 / $218.78
| Professional | | $186.21 | $186.21 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $199.53 / $457.09
| Professional | | $138.04 | $199.53 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $17.78 / $25.70 / $81.28
| Professional | 26 | $17.78 | $25.70 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $162.18 / $281.84
| Professional | TC | $112.20 | $162.18 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $131.83 / $457.09
| Professional | | $128.82 | $131.83 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $25.70 / $81.28
| Professional | 26 | $23.44 | $25.70 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $104.71 / $223.87
| Professional | TC | $104.71 | $104.71 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $204.17 / $316.23
| Professional | | $117.49 | $204.17 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.38 / $25.12 / $56.23
| Professional | 26 | $21.38 | $25.12 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $169.82 / $239.88
| Professional | TC | $95.50 | $169.82 | $239.88 |