- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $165.96 / $478.63
| Professional | | $134.90 | $165.96 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $81.28 / $257.04
| Professional | 26 | $64.57 | $81.28 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $57.54 / $79.43 / $251.19
| Professional | TC | $57.54 | $79.43 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $114.82 / $154.88 / $263.03
| Professional | | $114.82 | $154.88 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $79.43 / $128.82
| Professional | 26 | $54.95 | $79.43 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $52.48 / $75.86 / $131.83
| Professional | TC | $52.48 | $75.86 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $223.87 / $363.08
| Professional | | $173.78 | $223.87 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $114.82 / $173.78
| Professional | 26 | $83.18 | $114.82 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $89.13 / $109.65 / $186.21
| Professional | TC | $89.13 | $109.65 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $123.03 / $190.55 / $346.74
| Professional | | $123.03 | $190.55 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $102.33 / $154.88
| Professional | 26 | $81.28 | $102.33 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $33.88 / $97.72 / $165.96
| Professional | TC | $33.88 | $97.72 | $165.96 |