- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $371.54 / $812.83
| Professional | | $295.12 | $371.54 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $125.89 / $165.96
| Professional | 26 | $77.62 | $125.89 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $295.12 / $549.54
| Professional | TC | $223.87 | $295.12 | $549.54 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $426.58 / $426.58 / $426.58
| Facility | 26 | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $562.34 / $562.34 / $1,513.56
| Professional | | $562.34 | $562.34 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $288.40
| Professional | 26 | $91.20 | $91.20 | $288.40 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $467.74 / $467.74 / $549.54
| Professional | TC | $467.74 | $467.74 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $776.25 / $1,513.56
| Professional | | $467.74 | $776.25 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $100.00 / $218.78
| Professional | 26 | $89.13 | $100.00 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $275.42 / $549.54 / $1,174.90
| Professional | TC | $275.42 | $549.54 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $416.87 / $416.87
| Professional | | $416.87 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $72.44 / $72.44
| Professional | 26 | $72.44 | $72.44 | $72.44 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $346.74 / $346.74 / $346.74
| Professional | TC | $346.74 | $346.74 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $537.03 / $1,071.52
| Professional | | $371.54 | $537.03 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $91.20 / $190.55
| Professional | 26 | $70.79 | $91.20 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $295.12 / $446.68 / $912.01
| Professional | TC | $295.12 | $446.68 | $912.01 |