- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $257.04 / $416.87
| Professional | | $204.17 | $257.04 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $36.31 / $63.10
| Professional | 26 | $25.70 | $36.31 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $177.83 / $223.87 / $354.81
| Professional | TC | $177.83 | $223.87 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $338.84 / $398.11
| Professional | | $338.84 | $338.84 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $47.86 / $47.86 / $56.23
| Professional | 26 | $47.86 | $47.86 | $56.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $346.74
| Professional | TC | $295.12 | $295.12 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $128.82 / $338.84
| Professional | | $93.33 | $128.82 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $19.50 / $22.39 / $79.43
| Professional | 26 | $19.50 | $22.39 | $79.43 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $70.79 / $107.15 / $257.04
| Professional | TC | $70.79 | $107.15 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $208.93 / $380.19
| Professional | | $151.36 | $208.93 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.92 / $38.90 / $51.29
| Professional | 26 | $26.92 | $38.90 | $51.29 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $120.23 / $181.97 / $331.13
| Professional | TC | $120.23 | $181.97 | $331.13 |