- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $380.19 / $954.99
| Professional | | $257.04 | $380.19 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $162.18 / $281.84 / $741.31
| Professional | 26 | $162.18 | $281.84 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $97.72 / $112.20 / $363.08
| Professional | TC | $97.72 | $112.20 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $281.84 / $467.74
| Professional | | $213.80 | $281.84 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $125.89 / $181.97 / $295.12
| Professional | 26 | $125.89 | $181.97 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $70.79 / $102.33 / $169.82
| Professional | TC | $70.79 | $102.33 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $407.38 / $630.96
| Professional | | $302.00 | $407.38 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $190.55 / $263.03 / $398.11
| Professional | 26 | $190.55 | $263.03 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $112.20 / $147.91 / $239.88
| Professional | TC | $112.20 | $147.91 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $398.11 / $616.60
| Professional | | $309.03 | $398.11 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $194.98 / $245.47 / $354.81
| Professional | 26 | $194.98 | $245.47 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $114.82 / $151.36 / $213.80
| Professional | TC | $114.82 | $151.36 | $213.80 |