- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $199.53 / $354.81
| Professional | | $134.90 | $199.53 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $21.88 / $28.84 / $52.48
| Professional | 26 | $21.88 | $28.84 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $169.82 / $295.12
| Professional | TC | $114.82 | $169.82 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $288.40 / $288.40
| Professional | | $234.42 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $41.69 / $41.69
| Professional | 26 | $33.88 | $41.69 | $41.69 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $199.53 / $245.47 / $245.47
| Professional | TC | $199.53 | $245.47 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $275.42 / $407.38
| Professional | | $190.55 | $275.42 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $24.55 / $39.81 / $52.48
| Professional | 26 | $24.55 | $39.81 | $52.48 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $234.42 / $338.84
| Professional | TC | $162.18 | $234.42 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $331.13 / $691.83
| Professional | | $173.78 | $331.13 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $26.30 / $46.77 / $81.28
| Professional | 26 | $26.30 | $46.77 | $81.28 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $151.36 / $288.40 / $602.56
| Professional | TC | $151.36 | $288.40 | $602.56 |