- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $331.13 / $489.78
| Professional | | $288.40 | $331.13 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $102.33 / $151.36
| Professional | 26 | $87.10 | $102.33 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $199.53 / $234.42 / $331.13
| Professional | TC | $199.53 | $234.42 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $346.74 / $537.03
| Professional | | $245.47 | $346.74 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $77.62 / $151.36
| Professional | 26 | $70.79 | $77.62 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $181.97 / $363.08
| Professional | TC | $169.82 | $181.97 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $489.78 / $616.60
| Professional | | $269.15 | $489.78 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $125.89 / $199.53
| Professional | 26 | $70.79 | $125.89 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $199.53 / $407.38 / $446.68
| Professional | TC | $199.53 | $407.38 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $416.87 / $616.60
| Professional | | $251.19 | $416.87 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $112.20 / $165.96
| Professional | 26 | $75.86 | $112.20 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $186.21 / $295.12 / $446.68
| Professional | TC | $186.21 | $295.12 | $446.68 |