- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $316.23 / $794.33
| Professional | | $218.78 | $316.23 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $112.20 / $251.19
| Professional | 26 | $77.62 | $112.20 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $138.04 / $173.78 / $302.00
| Professional | TC | $138.04 | $173.78 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $199.53 / $208.93 / $288.40
| Professional | | $199.53 | $208.93 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $269.15 / $295.12
| Professional | | $181.97 | $269.15 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $102.33 / $112.20
| Professional | 26 | $69.18 | $102.33 | $112.20 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $165.96 / $181.97
| Professional | TC | $114.82 | $165.96 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $323.59 / $660.69
| Professional | | $177.83 | $323.59 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $125.89 / $239.88
| Professional | 26 | $83.18 | $125.89 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $141.25 / $208.93 / $446.68
| Professional | TC | $141.25 | $208.93 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $177.83 / $239.88 / $446.68
| Professional | | $177.83 | $239.88 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $87.10 / $158.49
| Professional | 26 | $66.07 | $87.10 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $151.36 / $263.03
| Professional | TC | $114.82 | $151.36 | $263.03 |