- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $588.84 / $588.84 / $588.84
| Professional | | $588.84 | $588.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $97.72 / $97.72 / $97.72
| Professional | 26 | $97.72 | $97.72 | $97.72 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $489.78 / $489.78 / $489.78
| Professional | TC | $489.78 | $489.78 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $776.25 / $1,230.27
| Professional | | $524.81 | $776.25 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $120.23 / $190.55
| Professional | 26 | $79.43 | $120.23 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $436.52 / $660.69 / $1,047.13
| Professional | TC | $436.52 | $660.69 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $107.15 / $630.96 / $1,737.80
| Professional | | $107.15 | $630.96 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $33.11 / $97.72 / $269.15
| Professional | 26 | $33.11 | $97.72 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $74.13 / $537.03 / $1,479.11
| Professional | TC | $74.13 | $537.03 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $245.47 / $831.76
| Professional | | $234.42 | $245.47 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $37.15 / $40.74 / $134.90
| Professional | 26 | $37.15 | $40.74 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $199.53 / $208.93 / $691.83
| Professional | TC | $199.53 | $208.93 | $691.83 |