- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $407.38 / $1,288.25
| Professional | | $346.74 | $407.38 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $141.25 / $575.44
| Professional | 26 | $102.33 | $141.25 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $234.42 / $269.15 / $416.87
| Professional | TC | $234.42 | $269.15 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $426.58 / $645.65
| Professional | | $295.12 | $426.58 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $95.50 / $186.21
| Professional | 26 | $87.10 | $95.50 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $223.87 / $436.52
| Professional | TC | $208.93 | $223.87 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $478.63 / $741.31
| Professional | | $323.59 | $478.63 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $154.88 / $245.47
| Professional | 26 | $87.10 | $154.88 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $239.88 / $346.74 / $524.81
| Professional | TC | $239.88 | $346.74 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $436.52 / $741.31
| Professional | | $316.23 | $436.52 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $95.50 / $138.04 / $199.53
| Professional | 26 | $95.50 | $138.04 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $213.80 / $302.00 / $537.03
| Professional | TC | $213.80 | $302.00 | $537.03 |