- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $338.84 / $691.83
| Professional | | $257.04 | $338.84 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $169.82 / $213.80 / $512.86
| Professional | 26 | $169.82 | $213.80 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $93.33 / $114.82 / $173.78
| Professional | TC | $93.33 | $114.82 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $281.84 / $512.86
| Professional | | $251.19 | $281.84 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $158.49 / $239.88 / $323.59
| Professional | 26 | $158.49 | $239.88 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $204.17 / $295.12 / $346.74
| Professional | | $204.17 | $295.12 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $131.83 / $186.21 / $223.87
| Professional | 26 | $131.83 | $186.21 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $104.71 / $125.89
| Professional | TC | $74.13 | $104.71 | $125.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $354.81 / $588.84
| Professional | | $257.04 | $354.81 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $165.96 / $223.87 / $354.81
| Professional | 26 | $165.96 | $223.87 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $91.20 / $128.82 / $208.93
| Professional | TC | $91.20 | $128.82 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $323.59 / $512.86
| Professional | | $218.78 | $323.59 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $141.25 / $204.17 / $323.59
| Professional | 26 | $141.25 | $204.17 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $81.28 / $117.49 / $186.21
| Professional | TC | $81.28 | $117.49 | $186.21 |