- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $162.18 / $204.17
| Professional | | $104.71 | $162.18 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $64.57 / $95.50
| Professional | 26 | $52.48 | $64.57 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $85.11 / $125.89
| Professional | TC | $52.48 | $85.11 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $186.21 / $186.21 / $426.58
| Professional | | $186.21 | $186.21 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $131.83 / $218.78 / $426.58
| Professional | | $131.83 | $218.78 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $83.18 / $213.80
| Professional | 26 | $48.98 | $83.18 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $66.07 / $123.03 / $194.98
| Professional | TC | $66.07 | $123.03 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $120.23 / $125.89 / $426.58
| Professional | | $120.23 | $125.89 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $64.57 / $213.80
| Professional | 26 | $64.57 | $64.57 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $60.26 / $61.66 / $97.72
| Professional | TC | $60.26 | $61.66 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $223.87 / $363.08
| Professional | | $112.20 | $223.87 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $56.23 / $87.10 / $138.04
| Professional | 26 | $56.23 | $87.10 | $138.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $56.23 / $97.72 / $162.18
| Professional | TC | $56.23 | $97.72 | $162.18 |