- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $245.47 / $295.12 / $457.09
| Professional | | $245.47 | $295.12 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $51.29 / $87.10 / $169.82
| Professional | 26 | $51.29 | $87.10 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $190.55 / $239.88 / $457.09
| Professional | TC | $190.55 | $239.88 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $478.63 / $478.63
| Professional | | $389.05 | $478.63 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $97.72 / $97.72
| Professional | 26 | $79.43 | $97.72 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $309.03 / $380.19 / $380.19
| Professional | TC | $309.03 | $380.19 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $457.09 / $616.60
| Professional | | $316.23 | $457.09 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $102.33 / $151.36
| Professional | 26 | $75.86 | $102.33 | $151.36 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $363.08 / $501.19
| Professional | TC | $223.87 | $363.08 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $575.44 / $1,230.27
| Professional | | $316.23 | $575.44 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $117.49 / $295.12
| Professional | 26 | $79.43 | $117.49 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $229.09 / $457.09 / $933.25
| Professional | TC | $229.09 | $457.09 | $933.25 |