- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $426.58 / $691.83
| Professional | | $275.42 | $426.58 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $125.89 / $190.55
| Professional | 26 | $93.33 | $125.89 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $190.55 / $295.12 / $457.09
| Professional | TC | $190.55 | $295.12 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $1,202.26
| Professional | | $380.19 | $380.19 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $776.25 / $1,380.38
| Professional | | $371.54 | $776.25 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $120.23 / $257.04
| Professional | 26 | $104.71 | $120.23 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $263.03 / $512.86 / $1,174.90
| Professional | TC | $263.03 | $512.86 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $426.58 / $426.58 / $426.58
| Professional | | $426.58 | $426.58 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Professional | 26 | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $338.84 / $338.84 / $338.84
| Professional | TC | $338.84 | $338.84 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $446.68 / $1,071.52
| Professional | | $302.00 | $446.68 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $83.18 / $107.15 / $223.87
| Professional | 26 | $83.18 | $107.15 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $213.80 / $302.00 / $794.33
| Professional | TC | $213.80 | $302.00 | $794.33 |