- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $125.89 / $478.63 / $1,348.96
| Professional | | $125.89 | $478.63 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $61.66 / $128.82 / $338.84
| Professional | 26 | $61.66 | $128.82 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $190.55 / $338.84 / $630.96
| Professional | TC | $190.55 | $338.84 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $100.00 / $363.08 / $363.08
| Professional | | $100.00 | $363.08 | $363.08 |
- 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 / $758.58
| Professional | | $363.08 | $501.19 | $758.58 |
- 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
- $173.78 / $398.11 / $645.65
| Professional | TC | $173.78 | $398.11 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $426.58 / $758.58
| Professional | | $389.05 | $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 / $630.96
| Professional | | $363.08 | $549.54 | $630.96 |
- 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 / $316.23 / $478.63
| Professional | TC | $181.97 | $316.23 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $398.11 / $724.44
| Professional | | $223.87 | $398.11 | $724.44 |
- 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
- $162.18 / $302.00 / $537.03
| Professional | TC | $162.18 | $302.00 | $537.03 |