- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $316.23 / $575.44
| Professional | | $204.17 | $316.23 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $52.48 / $112.20 / $134.90
| Professional | 26 | $52.48 | $112.20 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $199.53 / $398.11
| Professional | TC | $134.90 | $199.53 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $389.05 / $457.09
| Professional | | $389.05 | $389.05 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $114.82 / $114.82 / $114.82
| Professional | 26 | $114.82 | $114.82 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $354.81 / $354.81 / $354.81
| Professional | TC | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $478.63 / $977.24
| Professional | | $295.12 | $478.63 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $102.33 / $199.53
| Professional | 26 | $60.26 | $102.33 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $234.42 / $316.23 / $588.84
| Professional | TC | $234.42 | $316.23 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $281.84 / $977.24
| Professional | | $275.42 | $281.84 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $60.26 / $199.53
| Professional | 26 | $54.95 | $60.26 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $218.78 / $223.87 / $426.58
| Professional | TC | $218.78 | $223.87 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $467.74 / $676.08
| Professional | | $257.04 | $467.74 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $89.13 / $134.90
| Professional | 26 | $51.29 | $89.13 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $204.17 / $354.81 / $512.86
| Professional | TC | $204.17 | $354.81 | $512.86 |