- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $251.19 / $575.44
| Professional | | $181.97 | $251.19 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.84 / $52.48 / $125.89
| Professional | 26 | $28.84 | $52.48 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $218.78 / $478.63
| Professional | TC | $147.91 | $218.78 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $295.12 / $398.11
| Professional | | $263.03 | $295.12 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $45.71 / $45.71 / $60.26
| Professional | 26 | $45.71 | $45.71 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $338.84
| Professional | TC | $251.19 | $251.19 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $218.78 / $467.74
| Professional | | $95.50 | $218.78 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.39 / $45.71 / $77.62
| Professional | 26 | $22.39 | $45.71 | $77.62 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $72.44 / $173.78 / $457.09
| Professional | TC | $72.44 | $173.78 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $48.98 / $57.54
| Professional | 26 | $48.98 | $48.98 | $57.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $208.93 / $380.19
| Professional | | $109.65 | $208.93 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $37.15 / $60.26
| Professional | 26 | $25.12 | $37.15 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $83.18 / $181.97 / $331.13
| Professional | TC | $83.18 | $181.97 | $331.13 |