- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $169.82 / $309.03
| Professional | | $138.04 | $169.82 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $85.11 / $186.21
| Professional | 26 | $72.44 | $85.11 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $83.18 / $128.82
| Professional | TC | $57.54 | $83.18 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $141.25
| Professional | 26 | $128.82 | $128.82 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $165.96 / $194.98
| Professional | | $114.82 | $165.96 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $81.28 / $95.50
| Professional | 26 | $57.54 | $81.28 | $95.50 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $83.18 / $97.72
| Professional | TC | $57.54 | $83.18 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $117.49 / $173.78 / $288.40
| Professional | | $117.49 | $173.78 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $89.13 / $151.36
| Professional | 26 | $74.13 | $89.13 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $35.48 / $85.11 / $141.25
| Professional | TC | $35.48 | $85.11 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $147.91 / $234.42
| Professional | | $114.82 | $147.91 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $87.10 / $141.25
| Professional | 26 | $60.26 | $87.10 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $26.92 / $72.44 / $117.49
| Professional | TC | $26.92 | $72.44 | $117.49 |