- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $416.87 / $416.87
| Professional | | $416.87 | $416.87 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $63.10 / $63.10
| Professional | 26 | $63.10 | $63.10 | $63.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $354.81 / $354.81 / $354.81
| Professional | TC | $354.81 | $354.81 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $436.52 / $630.96 / $1,000.00
| Professional | | $436.52 | $630.96 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $81.28 / $128.82
| Professional | 26 | $53.70 | $81.28 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $363.08 / $549.54 / $870.96
| Professional | TC | $363.08 | $549.54 | $870.96 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $102.33 / $457.09 / $1,412.54
| Professional | | $102.33 | $457.09 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $22.39 / $64.57 / $181.97
| Professional | 26 | $22.39 | $64.57 | $181.97 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $79.43 / $398.11 / $1,230.27
| Professional | TC | $79.43 | $398.11 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $208.93 / $691.83
| Professional | | $173.78 | $208.93 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $24.55 / $27.54 / $93.33
| Professional | 26 | $24.55 | $27.54 | $93.33 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $147.91 / $181.97 / $602.56
| Professional | TC | $147.91 | $181.97 | $602.56 |