- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $478.63 / $1,318.26
| Professional | | $295.12 | $478.63 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $123.03 / $316.23
| Professional | 26 | $75.86 | $123.03 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $229.09 / $338.84 / $512.86
| Professional | TC | $229.09 | $338.84 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $489.78 / $912.01
| Professional | | $338.84 | $489.78 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $95.50 / $199.53
| Professional | 26 | $89.13 | $95.50 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $251.19 / $295.12 / $724.44
| Professional | TC | $251.19 | $295.12 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $831.76 / $1,174.90
| Professional | | $501.19 | $831.76 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $131.83 / $194.98 / $288.40
| Professional | 26 | $131.83 | $194.98 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $371.54 / $630.96 / $891.25
| Professional | TC | $371.54 | $630.96 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $549.54 / $776.25
| Professional | | $389.05 | $549.54 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $131.83 / $181.97
| Professional | 26 | $91.20 | $131.83 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $295.12 / $416.87 / $588.84
| Professional | TC | $295.12 | $416.87 | $588.84 |