- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $234.42 / $446.68 / $1,513.56
| Professional | | $234.42 | $446.68 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $112.20 / $380.19
| Professional | 26 | $75.86 | $112.20 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $186.21 / $338.84 / $1,023.29
| Professional | TC | $186.21 | $338.84 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $128.82 / $446.68 / $446.68
| Professional | | $128.82 | $446.68 | $446.68 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $158.49
| Facility | 26 | $128.82 | $128.82 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $380.19 / $489.78 / $891.25
| Professional | | $380.19 | $489.78 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $57.54 / $128.82 / $229.09
| Professional | 26 | $57.54 | $128.82 | $229.09 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $213.80 / $416.87 / $707.95
| Professional | TC | $213.80 | $416.87 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $478.63 / $489.78 / $741.31
| Professional | | $478.63 | $489.78 | $741.31 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $128.82 / $128.82 / $158.49
| Facility | 26 | $128.82 | $128.82 | $158.49 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $398.11 / $630.96 / $776.25
| Professional | | $398.11 | $630.96 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $128.82 / $190.55
| Professional | 26 | $85.11 | $128.82 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $213.80 / $331.13 / $478.63
| Professional | TC | $213.80 | $331.13 | $478.63 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $478.63 / $794.33
| Professional | | $251.19 | $478.63 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $75.86 / $85.11 / $190.55
| Professional | 26 | $75.86 | $85.11 | $190.55 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $173.78 / $331.13 / $575.44
| Professional | TC | $173.78 | $331.13 | $575.44 |