- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $426.58 / $602.56
| Professional | | $309.03 | $426.58 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $70.79 / $125.89 / $165.96
| Professional | 26 | $70.79 | $125.89 | $165.96 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $165.96 / $295.12 / $436.52
| Professional | TC | $165.96 | $295.12 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- 26
- Typical Low / Median / Typical High
- $398.11 / $398.11 / $398.11
| Facility | 26 | $398.11 | $398.11 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $323.59 / $323.59 / $1,096.48
| Professional | | $323.59 | $323.59 | $1,096.48 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $85.11 / $85.11 / $269.15
| Professional | 26 | $85.11 | $85.11 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $234.42 / $234.42 / $269.15
| Professional | TC | $234.42 | $234.42 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $309.03 / $630.96 / $1,202.26
| Professional | | $309.03 | $630.96 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $81.28 / $93.33 / $199.53
| Professional | 26 | $81.28 | $93.33 | $199.53 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $229.09 / $436.52 / $977.24
| Professional | TC | $229.09 | $436.52 | $977.24 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $363.08 / $363.08 / $363.08
| Professional | | $363.08 | $363.08 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $67.61 / $67.61 / $67.61
| Professional | 26 | $67.61 | $67.61 | $67.61 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $295.12 / $295.12 / $295.12
| Professional | TC | $295.12 | $295.12 | $295.12 |
- Facility/Professional
- Professional
- Modifier
- Typical Low / Median / Typical High
- $251.19 / $354.81 / $812.83
| Professional | | $251.19 | $354.81 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- 26
- Typical Low / Median / Typical High
- $64.57 / $83.18 / $173.78
| Professional | 26 | $64.57 | $83.18 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- TC
- Typical Low / Median / Typical High
- $186.21 / $263.03 / $724.44
| Professional | TC | $186.21 | $263.03 | $724.44 |