- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $194.98 / $316.23 / $891.25
| Professional | | $194.98 | $316.23 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $169.82 / $457.09
| Professional | 26 | $102.33 | $169.82 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $89.13 / $138.04 / $194.98
| Professional | TC | $89.13 | $138.04 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $331.13 / $616.60
| Professional | | $245.47 | $331.13 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $128.82 / $138.04 / $316.23
| Professional | 26 | $128.82 | $138.04 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $117.49 / $125.89 / $181.97
| Professional | TC | $117.49 | $125.89 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $549.54 / $812.83
| Professional | | $363.08 | $549.54 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $190.55 / $288.40 / $416.87
| Professional | 26 | $190.55 | $288.40 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $257.04 / $389.05
| Professional | TC | $173.78 | $257.04 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $363.08 / $489.78
| Professional | | $257.04 | $363.08 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $134.90 / $190.55 / $257.04
| Professional | 26 | $134.90 | $190.55 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $120.23 / $169.82 / $234.42
| Professional | TC | $120.23 | $169.82 | $234.42 |