- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $95.50 / $147.91 / $257.04
| Professional | | $95.50 | $147.91 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $64.57 / $134.90
| Professional | 26 | $53.70 | $64.57 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $46.77 / $72.44 / $144.54
| Professional | TC | $46.77 | $72.44 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $104.71 / $169.82 / $208.93
| Professional | | $104.71 | $169.82 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $85.11
| Professional | 26 | $85.11 | $85.11 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $85.11
| Professional | TC | $85.11 | $85.11 | $85.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $151.36 / $204.17 / $323.59
| Professional | | $151.36 | $204.17 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $102.33 / $134.90
| Professional | 26 | $61.66 | $102.33 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $77.62 / $104.71 / $165.96
| Professional | TC | $77.62 | $104.71 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $245.47 / $575.44
| Professional | | $194.98 | $245.47 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $117.49 / $204.17
| Professional | 26 | $66.07 | $117.49 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $95.50 / $144.54 / $363.08
| Professional | TC | $95.50 | $144.54 | $363.08 |