- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $398.11 / $758.58
| Professional | | $323.59 | $398.11 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $162.18 / $177.83 / $478.63
| Professional | 26 | $162.18 | $177.83 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $177.83 / $213.80 / $707.95
| Professional | TC | $177.83 | $213.80 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $489.78
| Professional | | $489.78 | $489.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $218.78 / $218.78 / $218.78
| Professional | 26 | $218.78 | $218.78 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $269.15 / $269.15 / $269.15
| Professional | TC | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $524.81 / $549.54
| Professional | | $223.87 | $524.81 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $281.84 / $295.12 / $295.12
| Professional | 26 | $281.84 | $295.12 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $239.88 / $251.19 / $251.19
| Professional | TC | $239.88 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $501.19 / $758.58
| Professional | | $426.58 | $501.19 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $190.55 / $223.87 / $338.84
| Professional | 26 | $190.55 | $223.87 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $234.42 / $281.84 / $416.87
| Professional | TC | $234.42 | $281.84 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $190.55 / $371.54 / $562.34
| Professional | | $190.55 | $371.54 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $112.20 / $288.40
| Professional | 26 | $107.15 | $112.20 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $83.18 / $257.04 / $275.42
| Professional | TC | $83.18 | $257.04 | $275.42 |