- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $616.60 / $616.60 / $616.60
| Professional | | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $74.13 / $74.13
| Professional | 26 | $74.13 | $74.13 | $74.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $537.03 / $537.03 / $537.03
| Professional | TC | $537.03 | $537.03 | $537.03 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $549.54 / $870.96 / $1,380.38
| Professional | | $549.54 | $870.96 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $60.26 / $91.20 / $144.54
| Professional | 26 | $60.26 | $91.20 | $144.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $489.78 / $758.58 / $1,174.90
| Professional | TC | $489.78 | $758.58 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $676.08 / $1,905.46
| Professional | | $275.42 | $676.08 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $25.70 / $74.13 / $204.17
| Professional | 26 | $25.70 | $74.13 | $204.17 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $251.19 / $588.84 / $1,698.24
| Professional | TC | $251.19 | $588.84 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $269.15 / $891.25
| Professional | | $251.19 | $269.15 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $28.18 / $30.20 / $102.33
| Professional | 26 | $28.18 | $30.20 | $102.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $239.88 / $794.33
| Professional | TC | $223.87 | $239.88 | $794.33 |