- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $138.04 / $229.09
| Professional | | $112.20 | $138.04 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $47.86 / $123.03
| Professional | 26 | $39.81 | $47.86 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $70.79 / $85.11 / $134.90
| Professional | TC | $70.79 | $85.11 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $109.65 / $223.87
| Professional | | $87.10 | $109.65 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $42.66 / $42.66 / $57.54
| Professional | 26 | $42.66 | $42.66 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $87.10 / $123.03 / $144.54
| Professional | | $87.10 | $123.03 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $31.62 / $45.71 / $53.70
| Professional | 26 | $31.62 | $45.71 | $53.70 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $54.95 / $77.62 / $91.20
| Professional | TC | $54.95 | $77.62 | $91.20 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $112.20 / $169.82 / $346.74
| Professional | | $112.20 | $169.82 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $50.12 / $93.33
| Professional | 26 | $39.81 | $50.12 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $114.82 / $223.87
| Professional | TC | $61.66 | $114.82 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $125.89 / $204.17
| Professional | | $91.20 | $125.89 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $48.98 / $79.43
| Professional | 26 | $33.11 | $48.98 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $54.95 / $77.62 / $138.04
| Professional | TC | $54.95 | $77.62 | $138.04 |