- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $177.83 / $446.68
| Professional | | $128.82 | $177.83 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $47.86 / $66.07 / $123.03
| Professional | 26 | $47.86 | $66.07 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $109.65 / $218.78
| Professional | TC | $81.28 | $109.65 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $199.53 / $354.81
| Professional | | $141.25 | $199.53 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $63.10 / $123.03
| Professional | 26 | $51.29 | $63.10 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $117.49 / $234.42
| Professional | TC | $91.20 | $117.49 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $275.42 / $323.59
| Professional | | $151.36 | $275.42 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $46.77 / $75.86 / $112.20
| Professional | 26 | $46.77 | $75.86 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $177.83 / $213.80
| Professional | TC | $93.33 | $177.83 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $169.82 / $263.03
| Professional | | $134.90 | $169.82 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $47.86 / $60.26 / $89.13
| Professional | 26 | $47.86 | $60.26 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $112.20 / $169.82
| Professional | TC | $91.20 | $112.20 | $169.82 |