- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $281.84 / $371.54 / $794.33
| Professional | | $281.84 | $371.54 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $107.15 / $234.42
| Professional | 26 | $85.11 | $107.15 | $234.42 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $194.98 / $263.03 / $562.34
| Professional | TC | $194.98 | $263.03 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $478.63 / $660.69
| Professional | | $346.74 | $478.63 | $660.69 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $141.25 / $165.96
| Professional | 26 | $102.33 | $141.25 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $245.47 / $338.84 / $398.11
| Professional | TC | $245.47 | $338.84 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $478.63 / $851.14
| Professional | | $416.87 | $478.63 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $125.89 / $154.88 / $251.19
| Professional | 26 | $125.89 | $154.88 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $295.12 / $338.84 / $602.56
| Professional | TC | $295.12 | $338.84 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $512.86 / $1,000.00
| Professional | | $436.52 | $512.86 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $125.89 / $147.91 / $295.12
| Professional | 26 | $125.89 | $147.91 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $309.03 / $363.08 / $707.95
| Professional | TC | $309.03 | $363.08 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $389.05 / $891.25
| Professional | | $295.12 | $389.05 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $120.23 / $257.04
| Professional | 26 | $89.13 | $120.23 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $204.17 / $269.15 / $630.96
| Professional | TC | $204.17 | $269.15 | $630.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $478.63 / $1,000.00
| Professional | | $389.05 | $478.63 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $123.03 / $147.91 / $269.15
| Professional | 26 | $123.03 | $147.91 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $263.03 / $331.13 / $602.56
| Professional | TC | $263.03 | $331.13 | $602.56 |