- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $457.09 / $1,412.54
| Professional | | $338.84 | $457.09 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $102.33 / $128.82 / $257.04
| Professional | 26 | $102.33 | $128.82 | $257.04 |
- Facility/Professional
- Professional
- Modifier
- 52
- Typical Low / Median / Typical High
- $151.36 / $151.36 / $169.82
| Professional | 52 | $151.36 | $151.36 | $169.82 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $229.09 / $309.03 / $602.56
| Professional | TC | $229.09 | $309.03 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $575.44
| Professional | | $162.18 | $162.18 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $162.18
| Facility | 26 | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $512.86 / $575.44
| Professional | | $354.81 | $512.86 | $575.44 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $134.90 / $162.18 / $194.98
| Professional | 26 | $134.90 | $162.18 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $338.84 / $416.87
| Professional | TC | $223.87 | $338.84 | $416.87 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $524.81 / $630.96 / $707.95
| Professional | | $524.81 | $630.96 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $162.18 / $162.18 / $162.18
| Facility | 26 | $162.18 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $354.81 / $575.44 / $831.76
| Professional | | $354.81 | $575.44 | $831.76 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $104.71 / $162.18 / $229.09
| Professional | 26 | $104.71 | $162.18 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $263.03 / $389.05 / $562.34
| Professional | TC | $263.03 | $389.05 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $446.68 / $562.34 / $1,023.29
| Professional | | $446.68 | $562.34 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $141.25 / $177.83 / $281.84
| Professional | 26 | $141.25 | $177.83 | $281.84 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $295.12 / $389.05 / $724.44
| Professional | TC | $295.12 | $389.05 | $724.44 |