- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $251.19 / $602.56
| Professional | | $251.19 | $251.19 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.02 / $38.02 / $97.72
| Professional | 26 | $38.02 | $38.02 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $213.80 / $213.80 / $489.78
| Professional | TC | $213.80 | $213.80 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $616.60 / $616.60
| Professional | | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $346.74 / $616.60
| Professional | | $346.74 | $346.74 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $107.15
| Professional | 26 | $97.72 | $97.72 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $239.88 / $239.88 / $524.81
| Professional | TC | $239.88 | $239.88 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $512.86 / $691.83 / $794.33
| Professional | | $512.86 | $691.83 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $575.44 / $891.25
| Professional | | $346.74 | $575.44 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $97.72 / $144.54
| Professional | 26 | $58.88 | $97.72 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $239.88 / $489.78 / $741.31
| Professional | TC | $239.88 | $489.78 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $245.47 / $691.83
| Professional | | $245.47 | $245.47 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $39.81 / $40.74 / $107.15
| Professional | 26 | $39.81 | $40.74 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $208.93 / $575.44
| Professional | TC | $208.93 | $208.93 | $575.44 |