- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $239.88 / $645.65
| Professional | | $134.90 | $239.88 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $36.31 / $52.48 / $141.25
| Professional | 26 | $36.31 | $52.48 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $123.03 / $281.84
| Professional | TC | $95.50 | $123.03 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $223.87 / $363.08
| Professional | | $162.18 | $223.87 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $46.77 / $58.88 / $102.33
| Professional | 26 | $46.77 | $58.88 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $141.25 / $257.04
| Professional | TC | $114.82 | $141.25 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $239.88 / $371.54
| Professional | | $144.54 | $239.88 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $41.69 / $70.79 / $104.71
| Professional | 26 | $41.69 | $70.79 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $173.78 / $269.15
| Professional | TC | $112.20 | $173.78 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $194.98 / $281.84
| Professional | | $165.96 | $194.98 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $50.12 / $57.54 / $72.44
| Professional | 26 | $50.12 | $57.54 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $120.23 / $138.04 / $186.21
| Professional | TC | $120.23 | $138.04 | $186.21 |