- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $257.04 / $478.63 / $1,479.11
| Professional | | $257.04 | $478.63 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $125.89 / $204.17
| Professional | 26 | $67.61 | $125.89 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $181.97 / $331.13 / $575.44
| Professional | TC | $181.97 | $331.13 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $467.74
| Professional | | $100.00 | $100.00 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $123.03
| Facility | 26 | $100.00 | $100.00 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $501.19 / $741.31
| Professional | | $363.08 | $501.19 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $44.67 / $100.00 / $177.83
| Professional | 26 | $44.67 | $100.00 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $177.83 / $380.19 / $645.65
| Professional | TC | $177.83 | $380.19 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $426.58 / $758.58
| Professional | | $398.11 | $426.58 | $758.58 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $100.00 / $100.00 / $123.03
| Facility | 26 | $100.00 | $100.00 | $123.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $549.54 / $645.65
| Professional | | $363.08 | $549.54 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $100.00 / $144.54
| Professional | 26 | $66.07 | $100.00 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $181.97 / $323.59 / $478.63
| Professional | TC | $181.97 | $323.59 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $398.11 / $660.69
| Professional | | $223.87 | $398.11 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $58.88 / $58.88 / $147.91
| Professional | 26 | $58.88 | $58.88 | $147.91 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $165.96 / $309.03 / $537.03
| Professional | TC | $165.96 | $309.03 | $537.03 |