- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $323.59 / $436.52
| Professional | | $257.04 | $323.59 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $107.15 / $141.25
| Professional | 26 | $91.20 | $107.15 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $213.80 / $323.59
| Professional | TC | $162.18 | $213.80 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $524.81 / $524.81
| Professional | | $426.58 | $524.81 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $144.54 / $177.83 / $177.83
| Professional | 26 | $144.54 | $177.83 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $281.84 / $346.74 / $346.74
| Professional | TC | $281.84 | $346.74 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $467.74 / $645.65
| Professional | | $346.74 | $467.74 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $138.04 / $165.96 / $229.09
| Professional | 26 | $138.04 | $165.96 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $213.80 / $302.00 / $426.58
| Professional | TC | $213.80 | $302.00 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $489.78 / $870.96
| Professional | | $281.84 | $489.78 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $114.82 / $181.97 / $338.84
| Professional | 26 | $114.82 | $181.97 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $165.96 / $288.40 / $588.84
| Professional | TC | $165.96 | $288.40 | $588.84 |