- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $426.58 / $933.25
| Professional | | $218.78 | $426.58 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $112.20 / $141.25 / $257.04
| Professional | 26 | $112.20 | $141.25 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $257.04 / $295.12 / $707.95
| Professional | TC | $257.04 | $295.12 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $630.96 / $630.96 / $630.96
| Facility | 26 | $630.96 | $630.96 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $616.60 / $1,819.70
| Professional | | $616.60 | $616.60 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $134.90 / $134.90 / $426.58
| Professional | 26 | $134.90 | $134.90 | $426.58 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $478.63 / $478.63 / $562.34
| Professional | TC | $478.63 | $478.63 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $537.03 / $1,023.29 / $1,737.80
| Professional | | $537.03 | $1,023.29 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $131.83 / $147.91 / $323.59
| Professional | 26 | $131.83 | $147.91 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $295.12 / $776.25 / $1,412.54
| Professional | TC | $295.12 | $776.25 | $1,412.54 |
- 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
- $107.15 / $107.15 / $107.15
| Professional | 26 | $107.15 | $107.15 | $107.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $380.19
| Professional | TC | $380.19 | $380.19 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $616.60 / $1,380.38
| Professional | | $436.52 | $616.60 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $100.00 / $131.83 / $281.84
| Professional | 26 | $100.00 | $131.83 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $331.13 / $467.74 / $1,202.26
| Professional | TC | $331.13 | $467.74 | $1,202.26 |