- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $302.00 / $398.11 / $676.08
| Professional | | $302.00 | $398.11 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $77.62 / $169.82 / $302.00
| Professional | 26 | $77.62 | $169.82 | $302.00 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $169.82 / $309.03 / $467.74
| Professional | TC | $169.82 | $309.03 | $467.74 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $512.86 / $512.86 / $512.86
| Facility | 26 | $512.86 | $512.86 | $512.86 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $407.38 / $407.38 / $1,584.89
| Professional | | $407.38 | $407.38 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $109.65 / $109.65 / $346.74
| Professional | 26 | $109.65 | $109.65 | $346.74 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $288.40 / $288.40 / $338.84
| Professional | TC | $288.40 | $288.40 | $338.84 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $371.54 / $676.08 / $1,230.27
| Professional | | $371.54 | $676.08 | $1,230.27 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $107.15 / $120.23 / $263.03
| Professional | 26 | $107.15 | $120.23 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $263.03 / $478.63 / $851.14
| Professional | TC | $263.03 | $478.63 | $851.14 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $467.74 / $467.74 / $467.74
| Professional | | $467.74 | $467.74 | $467.74 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $87.10 / $87.10 / $87.10
| Professional | 26 | $87.10 | $87.10 | $87.10 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $380.19 / $380.19 / $380.19
| Professional | TC | $380.19 | $380.19 | $380.19 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $288.40 / $416.87 / $954.99
| Professional | | $288.40 | $416.87 | $954.99 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $114.82 / $218.78
| Professional | 26 | $85.11 | $114.82 | $218.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $199.53 / $281.84 / $758.58
| Professional | TC | $199.53 | $281.84 | $758.58 |