- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $323.59 / $501.19
| Professional | | $204.17 | $323.59 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $74.13 / $128.82
| Professional | 26 | $61.66 | $74.13 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $213.80 / $380.19
| Professional | TC | $141.25 | $213.80 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $275.42 / $870.96
| Professional | | $275.42 | $275.42 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $524.81 / $912.01
| Professional | | $269.15 | $524.81 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $87.10 / $186.21
| Professional | 26 | $77.62 | $87.10 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $177.83 / $380.19 / $758.58
| Professional | TC | $177.83 | $380.19 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $288.40 / $288.40
| Professional | | $288.40 | $288.40 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $63.10
| Professional | 26 | $63.10 | $63.10 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $223.87 / $223.87
| Professional | TC | $223.87 | $223.87 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $309.03 / $707.95
| Professional | | $218.78 | $309.03 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $77.62 / $154.88
| Professional | 26 | $61.66 | $77.62 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $158.49 / $229.09 / $562.34
| Professional | TC | $158.49 | $229.09 | $562.34 |