- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $851.14 / $851.14 / $851.14
| Professional | | $851.14 | $851.14 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $89.13 / $89.13 / $89.13
| Professional | 26 | $89.13 | $89.13 | $89.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $758.58 / $758.58 / $758.58
| Professional | TC | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $794.33 / $1,202.26 / $1,905.46
| Professional | | $794.33 | $1,202.26 | $1,905.46 |
- 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
- $724.44 / $724.44 / $724.44
| Professional | TC | $724.44 | $724.44 | $724.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $501.19 / $933.25 / $2,691.53
| Professional | | $501.19 | $933.25 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $47.86 / $89.13 / $245.47
| Professional | 26 | $47.86 | $89.13 | $245.47 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $446.68 / $831.76 / $2,454.71
| Professional | TC | $446.68 | $831.76 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $354.81 / $1,202.26
| Professional | | $346.74 | $354.81 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.88 / $36.31 / $120.23
| Professional | 26 | $33.88 | $36.31 | $120.23 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $316.23 / $316.23 / $1,096.48
| Professional | TC | $316.23 | $316.23 | $1,096.48 |