- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $223.87 / $371.54 / $1,380.38
| Professional | | $223.87 | $371.54 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $85.11 / $239.88
| Professional | 26 | $57.54 | $85.11 | $239.88 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $144.54 / $281.84 / $489.78
| Professional | TC | $144.54 | $281.84 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $478.63
| Professional | | $93.33 | $93.33 | $478.63 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $114.82
| Facility | 26 | $93.33 | $93.33 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $407.38 / $691.83
| Professional | | $302.00 | $407.38 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $41.69 / $93.33 / $177.83
| Professional | 26 | $41.69 | $93.33 | $177.83 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $165.96 / $302.00 / $512.86
| Professional | TC | $165.96 | $302.00 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $398.11 / $645.65
| Professional | | $371.54 | $398.11 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $93.33 / $93.33 / $114.82
| Facility | 26 | $93.33 | $93.33 | $114.82 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $338.84 / $489.78 / $588.84
| Professional | | $338.84 | $489.78 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $63.10 / $95.50 / $141.25
| Professional | 26 | $63.10 | $95.50 | $141.25 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $295.12 / $398.11
| Professional | TC | $169.82 | $295.12 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $213.80 / $346.74 / $489.78
| Professional | | $213.80 | $346.74 | $489.78 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $54.95 / $63.10 / $158.49
| Professional | 26 | $54.95 | $63.10 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $158.49 / $275.42 / $436.52
| Professional | TC | $158.49 | $275.42 | $436.52 |