- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $61.66 / $83.18 / $218.78
| Professional | | $61.66 | $83.18 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $40.74 / $218.78
| Professional | 26 | $28.84 | $40.74 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $34.67 / $50.12 / $147.91
| Professional | TC | $34.67 | $50.12 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $75.86 / $102.33 / $173.78
| Professional | | $75.86 | $102.33 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $23.44 / $32.36 / $54.95
| Professional | 26 | $23.44 | $32.36 | $54.95 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $47.86 / $63.10 / $117.49
| Professional | TC | $47.86 | $63.10 | $117.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $147.91 / $213.80
| Professional | | $95.50 | $147.91 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $35.48 / $48.98 / $72.44
| Professional | 26 | $35.48 | $48.98 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $56.23 / $85.11 / $144.54
| Professional | TC | $56.23 | $85.11 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $54.95 / $112.20 / $190.55
| Professional | | $54.95 | $112.20 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $35.48 / $44.67 / $64.57
| Professional | 26 | $35.48 | $44.67 | $64.57 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $15.49 / $70.79 / $109.65
| Professional | TC | $15.49 | $70.79 | $109.65 |