- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $398.11 / $933.25
| Professional | | $204.17 | $398.11 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $117.49 / $204.17
| Professional | 26 | $66.07 | $117.49 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $281.84 / $416.87
| Professional | TC | $125.89 | $281.84 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $208.93 / $275.42 / $524.81
| Professional | | $208.93 | $275.42 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $93.33 / $162.18
| Professional | 26 | $64.57 | $93.33 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $128.82 / $186.21 / $354.81
| Professional | TC | $128.82 | $186.21 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $446.68 / $537.03
| Professional | | $239.88 | $446.68 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $112.20 / $165.96
| Professional | 26 | $69.18 | $112.20 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $295.12 / $363.08
| Professional | TC | $162.18 | $295.12 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $239.88 / $363.08 / $1,023.29
| Professional | | $239.88 | $363.08 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $89.13 / $123.03
| Professional | 26 | $67.61 | $89.13 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $245.47 / $851.14
| Professional | TC | $162.18 | $245.47 | $851.14 |