- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $354.81 / $1,096.48
| Professional | | $288.40 | $354.81 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $93.33 / $199.53
| Professional | 26 | $79.43 | $93.33 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $199.53 / $245.47 / $489.78
| Professional | TC | $199.53 | $245.47 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $229.09 / $257.04 / $1,122.02
| Professional | | $229.09 | $257.04 | $1,122.02 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $69.18 / $77.62 / $331.13
| Professional | 26 | $69.18 | $77.62 | $331.13 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $162.18 / $181.97 / $776.25
| Professional | TC | $162.18 | $181.97 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $275.42 / $389.05 / $602.56
| Professional | | $275.42 | $389.05 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $79.43 / $109.65 / $177.83
| Professional | 26 | $79.43 | $109.65 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $194.98 / $281.84 / $416.87
| Professional | TC | $194.98 | $281.84 | $416.87 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $213.80 / $380.19 / $380.19
| Facility | 26 | $213.80 | $380.19 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $363.08 / $2,238.72
| Professional | | $251.19 | $363.08 | $2,238.72 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $102.33 / $691.83
| Professional | 26 | $75.86 | $102.33 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $177.83 / $263.03 / $1,584.89
| Professional | TC | $177.83 | $263.03 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $323.59 / $575.44
| Professional | | $251.19 | $323.59 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $93.33 / $165.96
| Professional | 26 | $75.86 | $93.33 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $177.83 / $239.88 / $407.38
| Professional | TC | $177.83 | $239.88 | $407.38 |