- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $346.74 / $512.86
| Professional | | $275.42 | $346.74 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $100.00 / $162.18 / $281.84
| Professional | 26 | $100.00 | $162.18 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $208.93 / $338.84
| Professional | TC | $162.18 | $208.93 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $537.03 / $776.25
| Professional | | $371.54 | $537.03 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $128.82 / $138.04 / $323.59
| Professional | 26 | $128.82 | $138.04 | $323.59 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $245.47 / $281.84 / $389.05
| Professional | TC | $245.47 | $281.84 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $575.44 / $741.31 / $1,288.25
| Professional | | $575.44 | $741.31 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $190.55 / $288.40 / $416.87
| Professional | 26 | $190.55 | $288.40 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $389.05 / $489.78 / $891.25
| Professional | TC | $389.05 | $489.78 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $316.23 / $478.63 / $691.83
| Professional | | $316.23 | $478.63 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $134.90 / $190.55 / $257.04
| Professional | 26 | $134.90 | $190.55 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $181.97 / $316.23 / $436.52
| Professional | TC | $181.97 | $316.23 | $436.52 |