- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $346.74
| Professional | | $154.88 | $154.88 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $158.49
| Professional | 26 | $89.13 | $89.13 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $186.21
| Professional | TC | $67.61 | $67.61 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $354.81 / $416.87
| Professional | | $354.81 | $354.81 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $295.12 / $416.87
| Professional | | $229.09 | $295.12 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $117.49 / $169.82 / $512.86
| Professional | 26 | $117.49 | $169.82 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $147.91 / $218.78
| Professional | TC | $109.65 | $147.91 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $234.42 / $338.84
| Professional | | $229.09 | $234.42 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $117.49 / $117.49 / $173.78
| Professional | 26 | $117.49 | $117.49 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $109.65 / $117.49 / $165.96
| Professional | TC | $109.65 | $117.49 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $281.84 / $380.19
| Professional | | $144.54 | $281.84 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $147.91 / $229.09
| Professional | 26 | $79.43 | $147.91 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $131.83 / $165.96
| Professional | TC | $64.57 | $131.83 | $165.96 |