- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $91.20 / $112.20 / $177.83
| Professional | | $91.20 | $112.20 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $30.20 / $36.31 / $57.54
| Professional | 26 | $30.20 | $36.31 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $75.86 / $120.23
| Professional | TC | $61.66 | $75.86 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $186.21 / $186.21
| Professional | | $151.36 | $186.21 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $61.66 / $61.66
| Professional | 26 | $48.98 | $61.66 | $61.66 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $125.89 / $125.89
| Professional | TC | $102.33 | $125.89 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $162.18 / $204.17
| Professional | | $109.65 | $162.18 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $45.71 / $56.23 / $75.86
| Professional | 26 | $45.71 | $56.23 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $63.10 / $97.72 / $128.82
| Professional | TC | $63.10 | $97.72 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $64.57 / $165.96 / $208.93
| Professional | | $64.57 | $165.96 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $61.66 / $114.82
| Professional | 26 | $39.81 | $61.66 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.30 / $93.33 / $134.90
| Professional | TC | $26.30 | $93.33 | $134.90 |