- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $295.12 / $524.81 / $1,737.80
| Professional | | $295.12 | $524.81 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $125.89 / $239.88
| Professional | 26 | $70.79 | $125.89 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $218.78 / $389.05 / $758.58
| Professional | TC | $218.78 | $389.05 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $602.56
| Professional | | $109.65 | $109.65 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $134.90
| Facility | 26 | $109.65 | $109.65 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $346.74 / $501.19 / $812.83
| Professional | | $346.74 | $501.19 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $48.98 / $109.65 / $194.98
| Professional | 26 | $48.98 | $109.65 | $194.98 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $208.93 / $398.11 / $616.60
| Professional | TC | $208.93 | $398.11 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $501.19 / $707.95
| Professional | | $467.74 | $501.19 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $134.90
| Facility | 26 | $109.65 | $109.65 | $134.90 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $416.87 / $616.60 / $758.58
| Professional | | $416.87 | $616.60 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $72.44 / $109.65 / $158.49
| Professional | 26 | $72.44 | $109.65 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $223.87 / $338.84 / $478.63
| Professional | TC | $223.87 | $338.84 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $269.15 / $380.19 / $645.65
| Professional | | $269.15 | $380.19 | $645.65 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $74.13 / $162.18
| Professional | 26 | $64.57 | $74.13 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $204.17 / $323.59 / $524.81
| Professional | TC | $204.17 | $323.59 | $524.81 |