- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $309.03 / $549.54
| Professional | | $229.09 | $309.03 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $40.74 / $83.18
| Professional | 26 | $33.88 | $40.74 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $190.55 / $257.04 / $457.09
| Professional | TC | $190.55 | $257.04 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $446.68 / $446.68
| Professional | | $363.08 | $446.68 | $446.68 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $67.61 / $67.61
| Professional | 26 | $53.70 | $67.61 | $67.61 |
- 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
- $251.19 / $389.05 / $575.44
| Professional | | $251.19 | $389.05 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $38.90 / $57.54 / $83.18
| Professional | 26 | $38.90 | $57.54 | $83.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $213.80 / $331.13 / $501.19
| Professional | TC | $213.80 | $331.13 | $501.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $512.86 / $870.96
| Professional | | $338.84 | $512.86 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $50.12 / $74.13 / $125.89
| Professional | 26 | $50.12 | $74.13 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $295.12 / $436.52 / $741.31
| Professional | TC | $295.12 | $436.52 | $741.31 |