- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $263.03 / $426.58 / $691.83
| Professional | | $263.03 | $426.58 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $144.54 / $269.15
| Professional | 26 | $70.79 | $144.54 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $131.83 / $295.12 / $436.52
| Professional | TC | $131.83 | $295.12 | $436.52 |
- 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
- $275.42 / $275.42 / $870.96
| Professional | | $275.42 | $275.42 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $91.20 / $91.20 / $104.71
| Professional | 26 | $91.20 | $91.20 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $186.21 / $186.21 / $186.21
| Professional | TC | $186.21 | $186.21 | $186.21 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $616.60 / $1,122.02
| Professional | | $269.15 | $616.60 | $1,122.02 |
- 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
- $177.83 / $354.81 / $933.25
| Professional | TC | $177.83 | $354.81 | $933.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $338.84 / $338.84
| Professional | | $338.84 | $338.84 | $338.84 |
- 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
- $269.15 / $269.15 / $269.15
| Professional | TC | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $218.78 / $309.03 / $758.58
| Professional | | $218.78 | $309.03 | $758.58 |
- 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
- $144.54 / $208.93 / $630.96
| Professional | TC | $144.54 | $208.93 | $630.96 |