- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $575.44 / $2,089.30
| Professional | | $323.59 | $575.44 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $162.18 / $213.80 / $549.54
| Professional | 26 | $162.18 | $213.80 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $407.38 / $1,513.56
| Professional | TC | $162.18 | $407.38 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $549.54 / $549.54 / $549.54
| Professional | 26 | $549.54 | $549.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $173.78 / $549.54 / $776.25
| Professional | | $173.78 | $549.54 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $74.13 / $281.84 / $371.54
| Professional | 26 | $74.13 | $281.84 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $100.00 / $275.42 / $363.08
| Professional | TC | $100.00 | $275.42 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $331.13 / $331.13 / $331.13
| Professional | | $331.13 | $331.13 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $154.88 / $154.88 / $154.88
| Professional | 26 | $154.88 | $154.88 | $154.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $173.78 / $173.78
| Professional | TC | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $389.05 / $489.78 / $1,122.02
| Professional | | $389.05 | $489.78 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $194.98 / $302.00 / $524.81
| Professional | 26 | $194.98 | $302.00 | $524.81 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $218.78 / $338.84 / $588.84
| Professional | TC | $218.78 | $338.84 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $489.78 / $1,122.02
| Professional | | $354.81 | $489.78 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $223.87 / $457.09
| Professional | 26 | $109.65 | $223.87 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $251.19 / $602.56
| Professional | TC | $162.18 | $251.19 | $602.56 |