- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $141.25 / $169.82 / $223.87
| Professional | | $141.25 | $169.82 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $85.11 / $112.20
| Professional | 26 | $72.44 | $85.11 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $67.61 / $83.18 / $109.65
| Professional | TC | $67.61 | $83.18 | $109.65 |
- 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
- $114.82 / $144.54 / $144.54
| Professional | 26 | $114.82 | $144.54 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $117.49 / $144.54 / $144.54
| Professional | TC | $117.49 | $144.54 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $275.42 / $380.19
| Professional | | $223.87 | $275.42 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $134.90 / $181.97
| Professional | 26 | $109.65 | $134.90 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $138.04 / $194.98
| Professional | TC | $112.20 | $138.04 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $138.04 / $281.84 / $436.52
| Professional | | $138.04 | $281.84 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $147.91 / $275.42
| Professional | 26 | $91.20 | $147.91 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $47.86 / $141.25 / $186.21
| Professional | TC | $47.86 | $141.25 | $186.21 |