- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $251.19 / $389.05
| Professional | | $181.97 | $251.19 | $389.05 |
- 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
- $123.03 / $158.49 / $223.87
| Professional | TC | $123.03 | $158.49 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $331.13 / $331.13
| Professional | | $269.15 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $97.72 / $120.23 / $120.23
| Professional | 26 | $97.72 | $120.23 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $213.80 / $213.80
| Professional | TC | $173.78 | $213.80 | $213.80 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $354.81 / $489.78
| Professional | | $204.17 | $354.81 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $117.49 / $181.97
| Professional | 26 | $77.62 | $117.49 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $128.82 / $223.87 / $338.84
| Professional | TC | $128.82 | $223.87 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $363.08 / $676.08
| Professional | | $234.42 | $363.08 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $134.90 / $245.47
| Professional | 26 | $75.86 | $134.90 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $223.87 / $436.52
| Professional | TC | $144.54 | $223.87 | $436.52 |