- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $131.83 / $660.69
| Professional | | $97.72 | $131.83 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $31.62 / $66.07
| Professional | 26 | $22.91 | $31.62 | $66.07 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $75.86 / $91.20 / $128.82
| Professional | TC | $75.86 | $91.20 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $144.54 / $177.83 / $177.83
| Professional | | $144.54 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $34.67 / $43.65 / $43.65
| Professional | 26 | $34.67 | $43.65 | $43.65 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $107.15 / $134.90 / $134.90
| Professional | TC | $107.15 | $134.90 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $181.97 / $251.19
| Professional | | $109.65 | $181.97 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $27.54 / $41.69 / $63.10
| Professional | 26 | $27.54 | $41.69 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $134.90 / $194.98
| Professional | TC | $81.28 | $134.90 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $186.21 / $338.84
| Professional | | $109.65 | $186.21 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $27.54 / $51.29 / $87.10
| Professional | 26 | $27.54 | $51.29 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $141.25 / $251.19
| Professional | TC | $95.50 | $141.25 | $251.19 |