- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $295.12 / $812.83
| Professional | | $223.87 | $295.12 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $134.90 / $218.78 / $489.78
| Professional | 26 | $134.90 | $218.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $107.15 / $218.78
| Professional | TC | $87.10 | $107.15 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $181.97 / $239.88 / $407.38
| Professional | | $181.97 | $239.88 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $154.88 / $251.19
| Professional | 26 | $107.15 | $154.88 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $61.66 / $89.13 / $154.88
| Professional | TC | $61.66 | $89.13 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $346.74 / $549.54
| Professional | | $263.03 | $346.74 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $162.18 / $223.87 / $331.13
| Professional | 26 | $162.18 | $223.87 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $102.33 / $128.82 / $218.78
| Professional | TC | $102.33 | $128.82 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $338.84 / $537.03
| Professional | | $269.15 | $338.84 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $162.18 / $204.17 / $295.12
| Professional | 26 | $162.18 | $204.17 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $104.71 / $134.90 / $190.55
| Professional | TC | $104.71 | $134.90 | $190.55 |