- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $169.82 / $234.42
| Professional | | $125.89 | $169.82 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $54.95 / $83.18
| Professional | 26 | $39.81 | $54.95 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $85.11 / $114.82 / $162.18
| Professional | TC | $85.11 | $114.82 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $245.47 / $245.47
| Professional | | $199.53 | $245.47 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $75.86 / $75.86
| Professional | 26 | $61.66 | $75.86 | $75.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $169.82 / $169.82
| Professional | TC | $138.04 | $169.82 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $218.78 / $309.03
| Professional | | $151.36 | $218.78 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $47.86 / $72.44 / $114.82
| Professional | 26 | $47.86 | $72.44 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $141.25 / $213.80
| Professional | TC | $102.33 | $141.25 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $263.03 / $478.63
| Professional | | $208.93 | $263.03 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $47.86 / $87.10 / $154.88
| Professional | 26 | $47.86 | $87.10 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $181.97 / $323.59
| Professional | TC | $141.25 | $181.97 | $323.59 |