- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $134.90 / $181.97 / $363.08
| Professional | | $134.90 | $181.97 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $53.70 / $74.13 / $131.83
| Professional | 26 | $53.70 | $74.13 | $131.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $87.10 / $123.03 / $229.09
| Professional | TC | $87.10 | $123.03 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $588.84 / $588.84
| Professional | | $478.63 | $588.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $104.71 / $104.71
| Professional | 26 | $85.11 | $104.71 | $104.71 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $389.05 / $478.63 / $478.63
| Professional | TC | $389.05 | $478.63 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $489.78 / $707.95
| Professional | | $288.40 | $489.78 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $100.00 / $128.82
| Professional | 26 | $57.54 | $100.00 | $128.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $218.78 / $407.38 / $575.44
| Professional | TC | $218.78 | $407.38 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $616.60 / $1,023.29
| Professional | | $338.84 | $616.60 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $66.07 / $114.82 / $199.53
| Professional | 26 | $66.07 | $114.82 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $275.42 / $501.19 / $851.14
| Professional | TC | $275.42 | $501.19 | $851.14 |