- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $97.72 / $131.83 / $194.98
| Professional | | $97.72 | $131.83 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $28.84 / $36.31
| Professional | 26 | $21.88 | $28.84 | $36.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $64.57 / $109.65 / $158.49
| Professional | TC | $64.57 | $109.65 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $588.84 / $588.84
| Professional | | $588.84 | $588.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $169.82 / $251.19 / $588.84
| Professional | | $169.82 | $251.19 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.91 / $40.74 / $89.13
| Professional | 26 | $22.91 | $40.74 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $186.21 / $380.19
| Professional | TC | $141.25 | $186.21 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $165.96 / $165.96 / $588.84
| Professional | | $165.96 | $165.96 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.12 / $27.54 / $89.13
| Professional | 26 | $25.12 | $27.54 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $141.25 / $281.84
| Professional | TC | $138.04 | $141.25 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $263.03 / $407.38
| Professional | | $151.36 | $263.03 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $41.69 / $60.26
| Professional | 26 | $25.70 | $41.69 | $60.26 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $213.80 / $309.03
| Professional | TC | $125.89 | $213.80 | $309.03 |