- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $707.95 / $707.95
| Professional | | $501.19 | $707.95 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $134.90 / $208.93 / $218.78
| Professional | 26 | $134.90 | $208.93 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $363.08 / $489.78 / $489.78
| Professional | TC | $363.08 | $489.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $741.31 / $891.25
| Professional | | $588.84 | $741.31 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $162.18 / $204.17 / $245.47
| Professional | 26 | $162.18 | $204.17 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $426.58 / $537.03 / $645.65
| Professional | TC | $426.58 | $537.03 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $467.74 / $602.56
| Professional | | $346.74 | $467.74 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $114.82 / $154.88 / $223.87
| Professional | 26 | $114.82 | $154.88 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $229.09 / $380.19 / $489.78
| Professional | TC | $229.09 | $380.19 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $588.84 / $1,122.02
| Professional | | $407.38 | $588.84 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $162.18 / $316.23
| Professional | 26 | $102.33 | $162.18 | $316.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $309.03 / $426.58 / $812.83
| Professional | TC | $309.03 | $426.58 | $812.83 |