- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $269.15 / $616.60
| Professional | | $218.78 | $269.15 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $141.25 / $169.82 / $263.03
| Professional | 26 | $141.25 | $169.82 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $100.00 / $154.88
| Professional | TC | $79.43 | $100.00 | $154.88 |
- 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
- $223.87 / $275.42 / $275.42
| Professional | 26 | $223.87 | $275.42 | $275.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $134.90 / $165.96 / $165.96
| Professional | TC | $134.90 | $165.96 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $426.58 / $575.44
| Professional | | $346.74 | $426.58 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $208.93 / $263.03 / $354.81
| Professional | 26 | $208.93 | $263.03 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $128.82 / $162.18 / $223.87
| Professional | TC | $128.82 | $162.18 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $457.09 / $851.14
| Professional | | $346.74 | $457.09 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $208.93 / $288.40 / $524.81
| Professional | 26 | $208.93 | $288.40 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $125.89 / $173.78 / $331.13
| Professional | TC | $125.89 | $173.78 | $331.13 |